Consultation: Mark Lazarev, Inflammatory Bowel Disease Specialist
Date: August 31, 2010
Consultation With Johns Hopkins Gastroenterologist Mark Lazarev
What sort of patients do you treat?
Our typical referrals are patients with Crohn’s disease who have already been on a fair number of medications. Their disease is often pretty severe.
What makes treating these patients so challenging?
Weighing the risks and benefits of the available medicines is a big factor. Steroids were the traditional approach. They’re very effective at inducing a clinical remission in Crohn’s. But their long-term use leads to many side effects, including diabetes, adrenal insufficiency, osteoporosis, cataracts—the list goes on. Additionally, they’re not effective in keeping patients in remission.
Many other medications are available, although each has its own potential side effects, some of which can be serious.
What are some examples of those drugs and their downside?
Thiopurine agents have been around for decades and work by suppressing the immune system. These include 6-mercaptopurine and azathioprine. They’re effective at reducing the inflammation of Crohn’s, but they may increase the risk of infection as well as lymphoma.
A newer category of immunosuppressants blocks the inflammatory protein tumor necrosis factor. Anti-TNF agents are very effective in a majority of Crohn’s patients, but they’re also associated with an increased risk for infection, including reactivation of latent tuberculosis, and may increase the risk of lymphoma. They’re also very costly.
How do you decide what to prescribe?
We try to risk-stratify the patients. Some have a profile that increases their chances of developing complications from their disease, including strictures or fistulas that require surgery. Factors predictive for severe disease include young age, presence of fistulas around the anus, and need for steroids at the time of diagnosis. Additionally, patients with mutations in the NOD2 gene, as well as antibodies to certain bacterial species (such as ASCA) are at increased risk for a complicated course. These patients may require aggressive medical management, such as combination therapy with anti-TNF agents and thiopurines. A recent landmark study (SONIC) showed that the combination is superior to one or the other alone.
Is there any good news?
The wider range of treatments is helping more patients control their disease. For instance, studies have shown that patients on anti-TNF drugs have decreased rates of hospitalizations and surgery.
Also, many potential new medications are on the horizon. Some are in clinical trials and will probably become available in the next couple of years.
But even with the current treatments, we can do a lot to help patients. We have learned that immune-based therapy, if given early in the disease course, can change the natural history of the disease. I’ve seen patients who were virtually housebound return to work or school after receiving effective therapy.