New drugs safer than steroids for Crohn’s
Corticosteroids remain the leading therapy for Crohn’s disease despite the risk of serious side effects, according to a nationwide survey recently released by Vanderbilt University in Nashville, TN.
"While steroids can be effective in controlling symptoms for the short term, physicians need to monitor patients’ response to treatment carefully and evaluate their progress to minimize side effects, which can occur even after a brief period of time and be irreversible," explains Charles A. Sninsky, MD, associate director of gastroenterology, hepatology, and nutrition at Vanderbilt University Medical Center.
The national survey of more than 150 gastroenterologists and internists, each with a minimum of 10 Crohn’s patients treated with corticosteroids, found that physicians continue to use steroids to treat Crohn’s but are moving toward using alternative therapies. Findings include:
• 88% of physicians choose steroids to treat flare-ups in patients with severe cases.
• 75% of physicians choose steroids to treat moderate cases.
• 76% of physicians would keep patients on steroids for up to six months through an indefinite period to maintain remission.
• 19% would keep patients on steroids for 12 months.
• Overall, the average length of time physicians would use steroids to treat patients in remission is nine months.
Physicians reported continuing to prescribe steroids despite known side effects. Steroid-related side effects physicians reported noticing in their patients include:
• 36% of physicians reported their patients suffered weight gain.
• 21% reported fluid retention.
• 9% reported mood swings.
• 8% reported facial swelling.
Physicians recognized the potential long-term side effects of prolonged steroid use, including:
• 55% of physicians identified osteoporosis as a potential long-term effect.
• 29% identified cataracts.
• 27% identified high blood pressure.
"The bottom line is that steroids are generally not effective for the extended maintenance of Crohn’s disease, and, therefore, alternative therapies should be explored," says Sninsky.
Although 65% of physicians surveyed continue to rely on steroids because of their fast onset of pain relief, the survey also identified a growing move toward alternative therapies, including:
• 29% of physicians reported prescribing infliximab to treat severe Crohn’s flare-ups.
• 59% of physicians reported prescribing 5-ASA drugs for moderate cases of Crohn’s, and 20% report prescribing the drug for severe cases.
• 8% of physicians reported prescribing 6-mercaptopurine for moderate cases of Crohn’s, and 8% report prescribing it for severe cases.
• 30% of physicians reported believing that some Crohn’s patients can never be taken off steroids.
"Our major concern is a flare-up of Crohn’s symptoms when steroids are reduced. However, some of the symptoms that patients experience as they withdraw from steroids, like fatigue and joint pain, are due in part to the steroid use itself and a resulting adrenal insufficiency. These symptoms can decrease as patients are tapered off steroids. More important, these and other symptoms associated with steroid use can be avoided by alternative therapies," Sninsky says.
"The good news for all Crohn’s patients is there are newer, safer, and well-tolerated medications available, like infliximab, that are emerging as proven treatment options that not only provide quick relief of symptoms without the side effects of steroids, but also help in healing the intestines," he notes. "In recent studies, we’ve seen that patients who receive infliximab are able to stop or greatly reduce their use of steroids."
Treatment with infliximab also greatly reduces patients’ need for other medical services, according to a study presented at the American College of Gastroenterology annual meeting in New York City. Researchers reviewed electronic medical records and charts and assessed the use of inpatient and outpatient medical services at the University of Chicago Medical Center from three years prior to infliximab treatment to one year following infliximab treatment.
Patients treated with infliximab experienced the following results:
• 38% decrease in overall annual incidence of all surgeries;
• 43% decrease in endoscopies;
• 66% decrease in patient visits to the emergency room;
• 16% decrease in all outpatient visits;
• 20% decrease in outpatient gastrointestinal visits;
• 12% decrease in radiology exams.
Some patients with Crohn’s disease develop fistulas that burrow through the bowel wall into nearby organs or through the surface of the skin. When looking specifically at the subset of Crohn’s patients with fistulas, researchers found that infliximab treatment showed similar reductions in overall medical services.
Specific findings include:
• 59% decrease in hospitalizations;
• 66% decrease in surgeries;
• 64% decrease in emergency room visits;
• 27% decrease in outpatient visits;
• 40% decrease in radiology exams.
"Given the high costs associated with surgery and hospitalization, the use of infliximab may translate to an overall savings for these patients and the health care system," says Russell D. Cohen, MD, assistant professor of clinical medicine and co-director for clinical inflammatory bowel disease at the University of Chicago Medical Center.
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