Risks From Conventional Treatment
So who should take a biologic for Crohn's? Many gastroenterologists reserve these drugs for people who have not responded to conventional medications that suppress the immune system. But some gastroenterologists may treat Crohn's more aggressively.
"If you let inflammation go, inflammation leads to scarring and scarring leads to narrowing of the intestines, which becomes a surgical problem," says Prabhakar Swaroop, MD, assistant professor and director of the Inflammatory Bowel Disease Program at the University of Texas Southwestern Medical Center in Dallas. "You want to treat the person aggressively to prevent these problems."
"In addition to improving symptoms, the anti-TNF modifiers are associated with mucosal healing," says Bloomfeld. "We hope that in healing the mucosa we can stop the progression of the disease and prevent complications of Crohn's that result in hospitalization and surgery."
While there are other treatments that suppress the immune system to treat Crohn's, they too have side effects, says Bloomfeld. Like the biologics, drugs that suppress the immune system increase the risk of lymphomas and infections, which can be severe.
Cortiosteroids like prednisone, for example, can cause a wide range of adverse effects including weight gain, mood swings, bone loss, skin bruising, high blood pressure, and high blood sugar. Those side effects are why corticosteroids may be used to control a flare, but aren't the choice to treat Crohn's over a long period of time. "The stop-gap method, which is steroids, is something we cannot use long term," says Swaroop.
Biologics: Weighing the Risks and Benefits
When prescribing any drug, doctors look at the potential risks against the benefits they hope or expect to achieve. Although doctors don't all share the same philosophy on when to start biologics for Crohn's disease, they do agree that biologics should be used when people have severe disease that can lead to permanent damage and make surgery unavoidable.
Swaroop says he looks for signs that the disease is progressing, such as how long between a person's diagnosis of Crohn's and when they have fistulas. "These are the patients who generally do better on biologics, who have the quality of life improvement, who are able to avoid surgery and get back in the workforce," he says.
Before prescribing biologics, doctors check for potential problems. "In the beginning, of course, we go ahead and make sure the person does not have an active liver infection or TB," says Marie Borum, MD, professor of medicine and director of the Division of Gastroenterology and Liver Diseases at George Washington University in Washington, D.C.
Once someone starts a biologic, the doctor looks for side effects in order to find them before they become serious. Monitoring includes include lab tests and possibly regular skin checks for signs of skin cancer.