Question:
I was diagnosed with ulcerative colitis and Crohn's disease four years ago. I am 53. I was given Asacol and prednisone for six months. Asacol was not helping my symptoms so my doctor advised me to try Remicade, which I have been on for three years. I usually have the infusion every eight weeks. My doctor has advised me to stay on it as a maintenance program forever. I have not gone for an infusion since February. I also have switched employment, from which I had a lot of stress. Do you think this will create a problem if I stop the Remicade? I am not having any symptoms at this time. My previous symptoms were nausea, fever, eight bowel movements a day.

Dr. Cross:
Remicade is a very effective therapy for patients with ulcerative colitis. It is most effective when given three times in the first 6 weeks (induction therapy) followed by every 8 weeks thereafter (maintenance therapy). Studies in both patients with Crohn’s disease and ulcerative colitis have clearly shown that patient outcomes are better if the drug is continued on a regular basis (at least every 8 weeks). Also, we have learned from past experiences that using the drug intermittently (“on-demand”) can result in patients developing blocking antibodies to the drug. These antibodies can result in future allergic reactions during infusions and can lead to loss of response to the drug. If you lose response to the drug, you may not respond to other drugs in this class like Humira or Cimzia (which are not currently FDA approved for the treatment of ulcerative colitis). I would strongly advise that you contact your provider to discuss these issues and to schedule an infusion.

Question:
I was diagnosed with mild-moderate ulcerative colitis a year ago. I also have irritable bowel syndrome. It has progressed into severe UC just recently. I went on 50 mg of prednisone but still have watery bowel movements 1-3 times in the morning. My doctor wants to put me on Remicade and 6MP. Do you think I could just go on the 6MP since symptoms are not that bad and I can wait the three months for it to work?

Dr. Cross:
Before changing therapies, I make sure that patients have had an adequate trial of high dose steroids. This usually requires 60 mg of prednisone for 30 days or inpatient admission for steroids through an IV line for 3-5 days. Have you been on the prednisone for at least 30 days?

If you have been on an adequate trial and are not completely better, I usually confirm that the symptoms are from UC and not IBS prior to escalating therapy. This can be established with a flexible sigmoidoscopy. If the UC is still active and your symptoms are mild to moderate, it is reasonable to use either 6MP or Remicade. The only down side of using the 6MP is that you will require ongoing high dose steroids for a few months until the drug takes effect. The Remicade should work more rapidly and will allow you to start the steroid taper sooner.

The only other reason to use both drugs in your case is to prevent allergic reactions to the Remicade. This benefit must be weighed against the increased risk of infection and certain types of cancer when using drugs. You should discuss the risks and benefits of this approach with your provider before starting both drugs.

Question:
My 19 year-old son has severe perianal disease. He was on Remicade and 6MP for five years. He was taken off Remicade because of information about fatalities with the 6MP. He flared and was put on Humira. After 10 weeks the CT scan shows most of the colon cleared, but still significant proctitis and fistula. New doctor thinks Remicade would be better than Humira. He never had reactions before, I am afraid to let him go back on after being off it for two years. Would very slow infusion, and pre-medication with Tylenol, Benadryl and steroids help?

Dr. Cross:
In patients that have had a long drug holiday off of Remicade (4 months or more since last infusion), we recommend that patients receive steroids through an IV line, Benadryl by mouth, and Tylenol by mouth 30 minutes prior to the infusion. Also, we prescribe a Solumedrol (steroid) dose pack after the infusion. We repeat this for at least one more infusion then attempt to continue the Remicade without steroids pre and post infusion. Since your son continued to use 6 MP, he may not have developed antibodies that produce the allergic reaction.

Another thing to consider in patients with perianal fistulas is use of surgical therapy. It has been shown that failure to drain areas of infection results in decreased response to medical therapy in patients with perianal fistulas. Referral to a colorectal surgeon for an exam under anesthesia with drainage of abscess and seton placement may help fistula healing.

Question:
I am a 45 year old male with Crohn's disease, diagnosed 11 years ago, initial fare was treated with prednisone, maintenance has been with sulfasalazine, three 500 mg three times a day. Only two flare-ups in ten years so I feel very fortunate. I was prescribed Entocort on the latest flare-up (currently starting the second month.) and it has worked very well. I have not noticed any side effects. My doctor would like to start me on Imuran to supplement the azulfidine, but after researching the drug I'm not so sure I want to. The side effects and possible long-term risks seem pretty scary. I've heard Entocort has recently been approved for long-term use. Is that an alternative I should consider?

Dr. Cross:
How many times have you received steroids in the last 10 years? If this is your first course of steroids, it would be reasonable to taper the Entocort off without adding Imuran. If you have had repeated courses of steroids, transitioning to an immune suppressant like Imuran is very reasonable. There is data up to two years showing that moderate doses of Entocort are safe to take. It also appears that Entocort can delay recurrences of symptoms for about a year.

Question:
After having a colon resection and bladder repair because of a fistula almost seven years ago I have had good control of my symptoms. I am on 6MP, Asacol and metronidazole. However, in the past four years I've had three incidents of scleritis. These were treated with prednisone starting at 60 mg and tapering over a 2-3 week period. Does this indicate that the Crohn's is not sufficiently controlled?

Dr. Cross:
Not necessarily. Many of the extraintestinal manifestations of Crohn’s do not correlate with underlying bowel activity. If the bowel symptoms were active when the scleritis flared, this probably indicates poor control. Drugs like Remicade have been used with some success in patients with recurrent eye symptoms. You should discuss with your gastroenterologist and ophthalmologist whether increasing the 6 MP or adding a drug like Remicade would be reasonable to prevent flares of scleritis and need for repeated courses of prednisone.

Question:
Two years ago I developed an abscess which turned into an anal fistula (transsphincteric-through both sphincter muscles). I have had several attempts at a surgisis plug which have been unsuccessful. The fistula is low was told after and MRI that it is at 11:00 o'clock. I do not want to undergo a fistulotomy and I might lose control. I am 20 years old and feel this should be a last resort. Is there any treatment which could prevent this surgery?

Dr. Cross:
We place patients like you in a protocol at the University of Maryland. First, patients are started on combination antibiotics with Cipro and Flagyl twice daily. Second, patients undergo a pelvic MRI to help stage the fistula. Third, patients undergo an exam under anesthesia, with drainage of any abscess and placement of setons (drains). Once the setons are in, we start aggressive medical therapy with both Remicade and either 6 MP or Imuran. We evaluate therapy after 2 and 6 months. If symptoms are resolved, we repeat a MRI. If the MRI shows healing of the fistula, we ask the surgeon to remove the setons (drains) and continue medical therapy. I have found that when we do not treat aggressively like this, we have incomplete healing. Further, we have not had good success with glue and plugs. You are not a fistulotomy candidate because of the fistula location.

Question:
My husband is 51 years old and was diagnosed two years ago with IBD. He presented with blood in the stool for more than two years. He had a history of hemorrhoids and thought that was the problem. He had some frequency of bowel movements and stomach upset but nothing alarming. On colonoscopy he was found to have lesions throughout the bowl suggesting Crohn's but findings were inconclusive. He was started on mesalamine and then prednisone, also Rowasa and sometimes Hydrocort enemas. A repeat colonoscopy about nine months later showed much improvement, only one lesion in the distal colon. His doctor thought he had UC, not Crohn's. He had frequent bloody stools, mucous stools, cramping and eventually was up to 6 grams a day of mesalamine and 30 mg of prednisone, If he tried to taper he flared. 6MP was added, 100 mg/day. He has also developed arthritis symptoms and is also seeing a rheumatologist. It is complicated by the fact that he has hepatitis C and took interferon about 15 years ago. His doctor did a liver biopsy and there is stage one damage, but the enzymes are normal. Can you please suggest a regimen that would address both the arthritis and the UC?

Dr. Cross:
The arthritis in patients with UC can be complicated. One type of arthritis improves when the UC goes into remission with medical therapy. The other type can be active even when the bowel disease is in remission. However, this form of arthritis also responds to medical therapy. The first thing I would suggest is confirming that the disease is not active by repeating a sigmoidoscopy or colonoscopy. I would also exclude infections such as Clostridium difficile. I would tell your husband to discontinue all nonsteroidal anti-inflammatory drugs. If the disease is still active, I think either increasing the 6MP or adding Remicade is reasonable. Referral to surgery for colectomy (removal of colon) is also reasonable.

Question:
I was diagnosed with Crohn's disease two months ago and my doctor started me on Cimzia. I have done some research on Cimzia and it says this drug is usually given after other medications have failed. Everyone is telling me to get a second opinion. Are there other drug options I should be investigating first?

Dr. Cross:
That is not true. Cimzia is a perfectly acceptable first line biologic therapy in patients with Crohn’s disease. It is not restricted to patients that have failed Remicade or Humira. If the drug has worked for you, I would encourage you to continue this agent under your provider’s care.

Question:
I am a 50-year old make suffering from proctocolitis for the past six years, I could not tolerate Imuran due to macrocytosis and steroid dependency at 30 mg per a non-stop for more than two years. I have never been symptom free. I am now seeing side-effects, such as cataracts. What are my options? Should I have surgery?

Dr. Cross:
Macrocytosis is a normal finding in patients on Imuran; in fact this is often one way providers monitor compliance in patients on the drug. If the drug was stopped for that reason only, I would consider restarting the drug and continuing for several months to see if you can taper the prednisone to off or lower the dose. Other options include Remicade which is a medication given through the vein. Colectomy (removal of the colon) is curative if you have ulcerative colitis. Other options would include off-label treatments (methotrexate, avandia, tacrolimus) or referral to a clinical trial of an investigational drug.

Question:
I was just recently diagnosed with Crohn's. It seems that not matter what I eat everything goes right through me. What types of food can I eat or is there another answer?

Dr. Cross:
There is not a single correct diet for a patient with Crohn’s disease. If a patient has a stricture or blockage, we usually recommend an ultra low residual diet (melts in your mouth diet). For all other patients, we use a common sense approach. I tell patients to keep a diary of foods that seem to bother them. These should be avoided if possible. Also, many patients have trouble with large amounts of milk products when they are flaring due to lactase deficiency. This can be addressed by avoiding milk products or using lactaid tablets. It is also reasonable to recommend supplementation with a multivitamin and to use 1000-1500 mg per day of calcium and 800 IU per day of vitamin D.