By Kimberly Weaver, MD, as told to Stephanie Watson
I'm fortunate to work as a gastroenterologist at a time when we have many excellent options for treating Crohn's disease, including new biologic and small-molecule drugs. The number of new treatments that researchers are studying in clinical trials makes me even more hopeful about the outlook for people with this chronic inflammatory condition.
Choosing the Right Treatment
Treatment for Crohn's disease is very personalized. I always try to include my patients in the decision-making process. When choosing a medication, I consider its effectiveness and safety. I also consider things like:
- The person's age
- Their overall health
- Whether they also have skin and joint conditions
- Where and how serious their gut inflammation is
- Whether they have strictures or any other complications of Crohn's disease
We also talk about their values, including whether they'd rather take medicine as an injection at home vs. an infusion at the hospital.
The goal in treating Crohn's is to improve symptoms and quality of life while preventing complications. We usually use a "treat to target" strategy. That means we try to clear up both symptoms and inflammation to put the disease into remission.
Biologics are treatments we prescribe for moderate to severe Crohn's disease. These are large proteins that are made from living organisms. They target the specific processes in the body that trigger inflammation.
Several classes of biologics are approved to treat Crohn’s disease. Each works against a different protein that causes inflammation.
We have medications that inhibit the protein called tumor necrosis factor (TNF), including:
- Adalimumab (Humira)
- Certolizumab pegol (Cimzia)
- Infliximab (Remicade)
More recently approved biologics include:
- Ustekinumab (Stelara), which works by blocking the proteins interleukin 12 and 23 (IL-12 and IL-23)
- Vedolizumab (Entyvio), which keeps white blood cells from moving into the gut
Surgery has always played an important role in managing Crohn's, and it can be lifesaving. But thanks to these newer biologic drugs, rates of surgery seem to be decreasing. Our medications control inflammation better, so they may help people avoid surgeries they might have needed in the past.
Searching for Better Outcomes
We're trying to better understand which patients will respond best to a specific medication, especially since our arsenal of therapies has expanded. We're trying to identify biomarkers -- substances in a person's blood -- that help point us to the right treatment for them.
We've learned that some people with Crohn's carry a genetic marker called the human leukocyte antigen (HLA) DQA1*05 allele. This could put them at high risk of forming antibodies to anti-TNF biologics. That can make these drugs less effective.
If we know someone carries this marker, we often use combination therapy with an anti-TNF biologic plus an immune-modulating drug. Or we use a non-anti-TNF biologic as the first treatment.
It's not part of our standard practice to check for this marker because insurance may not cover the cost. But in the future, doing a blood test to check for this or other markers could help us choose the treatment that will work best for a certain patient.
Why I'm Optimistic
This is an exciting time to be treating Crohn's disease. We've made great strides in both diagnosing and managing this disease. And we've gotten better at preventing complications.
Many drugs are in development for Crohn’s disease, some of which have new therapeutic targets. Some of these are pills, including:
- The sphingosine-1-phosphate (S1P) receptor modulator ozanimod (Zeposia)
- The selective Janus kinase (JAK) 1 inhibitor upadacitinib (Rinvoq)
That's exciting because people can take them by mouth, instead of having to go to their doctor's office for an infusion or give themselves a shot.
I'm also excited about biologic medications in development that block IL-23. For treating another inflammatory disease, psoriasis, head-to-head studies found IL-23 inhibitors to be more effective than ustekinumab (Stelara) and adalimumab (Humira).
Although we're still waiting for results of the Crohn's disease clinical trials, targeting IL-23 seems to be a promising option.
As with most other long-lasting medical conditions, including high blood pressure and diabetes, we still don't have a cure for Crohn's disease. It's hard to say how far we are from one. Crohn’s disease is complex. A combination of genetic, immune system, and environmental and lifestyle factors play a role in causing it.
Also, there are many different types of Crohn's disease. Someone who has inflammation only in their small bowel is probably different from someone with inflammation in their colon. Some patients have a very mild disease course. Others have a very serious one, and get complications like strictures or fistulas. Unfortunately, no one magic pill can treat every form of the disease.
Another challenge is the high cost of treatment. Biologic drugs can be very expensive. Depending on insurance coverage, a single treatment can cost thousands of dollars.
We need to make these drugs more affordable so they're accessible to everyone. Though I strive to provide my patients with the best possible care, insurance companies often deny coverage for biologic drugs. This includes treatments my patients have been on for several years.
Learning More About Crohn's Disease
Our aim is to develop more effective treatments for Crohn’s disease. We continue to work toward a cure and, ultimately, a way to prevent this condition.
Clinical trials offer people with Crohn’s access to new and emerging treatments. If you want to learn more about clinical trials, talk to the gastroenterologist who treats your Crohn's disease, or visit the Crohn's & Colitis Foundation website.
Photo Credit: daizuoxin / Getty Images
Gastroenterology: "HLA-DQA*05 Carriage Associated with Development of Anti-Drug Antibodies to Infliximab and Adalimumab in Patients with Crohn's Disease."
Inflammatory Bowel Diseases: "Incidence rates for surgery in Crohn's disease have decreased: A population-based time-trend analysis."
Kimberly Weaver, MD, assistant professor, division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC.