Tests to Spot, Drugs to Suppress

[MUSIC PLAYING] Welcome, everyone. I'm Dr. John Whyte, the Chief Medical Officer at WebMD. Crohn's disease is a chronic inflammatory bowel disease that affects the lining of the digestive tract. Symptoms include abdominal pain, diarrhea, weight loss, low blood count, as well as fatigue. But how do doctors tell if you have Crohn's? And if you do, what are your treatment options?

Joining me to discuss the best approach to diagnosis and treatment are two experts, Dr. Shannon Chang. She's the director of clinical operations at the Inflammatory Bowel Disease Center at NYU Langone Medical Center and Chair Emeritus of the Medical Advisory Committee of Greater New York Chapter for the Crohn's and Colitis Foundation.

I'm also joined by Dr. Thomas Ullman, the Chief of the Division of Gastroenterology at Montefiore Medical Center, a Professor of Medicine at Albert Einstein College of Medicine, and a member of the National Scientific Advisory Council of the Crohn's and Colitis Foundation. Welcome, doctors.

Hi.

Hi.

I want to start off with how do you diagnose Crohn's disease? So if a patient is having the symptoms of abdominal pain, diarrhea, that can be other conditions as well. Patients typically aren't going to go to the gastroenterologist first. They're going to see their primary care physician. So what's those lab tests that's going to be ordered first? And what's the diagnostic workup?

Some common lab tests that a primary care might send to look might include things like a CBC looking at is the patient newly anemic? Is their white blood cell count up, indicating possible inflammation or infection? How is their albumin? Is the albumin low? That could suggest that there's some sort of protein-losing enteropathy going on as well. And then sometimes the C-reactive protein, that can be elevated, suggesting that something is going on but, again, nonspecific.

So we sometimes send something from the stool called a fecal calprotectin that is specific to the gut that looks for inflammation. And if that's elevated, that's a sign, OK, maybe there's something going on inflammatory within the bowels.

But clearly, colonoscopy plays a key role in diagnosis. And I wanted to ask, is the colonoscopy for diagnosis of Crohn's different than the colonoscopy that many people hear about in the screening for colorectal cancer?

The colonoscopy that we do for diagnosing Crohn's disease is very, very similar to that which we do. Obviously, same instrument, same preparation, sorry. And it does take a little bit longer. We're obligated, to some extent, to get that tip of that scope into the last part of the small intestine in addition to examining the entirety of the large intestine. And instead of looking for polyps, we're looking for areas of active inflammation that would give us the sense that this was, in fact, Crohn's disease.

We do wait often until we get the tissue looked at under the microscope, but really, it's virtually the same. Might take a little bit longer because sometimes it does take a hair longer to get into that last part of the small intestine.

So you get the diagnosis of Crohn's disease. What's the implication that viewers need to know in terms of the impact on morbidity as well as mortality?

So thankfully, there is no impact on mortality with Crohn's disease. We're very proud to say that.

Normal life span.

Normal lifespan.

Let me say the average lifespan.

Average, right. So we all have different things plaguing the population right now.

But it's not going to make you die sooner.

No, it will not. And then in terms of morbidity, there are potentially increased risks of things like surgery that might be required if the inflammation is not controlled. There are downstream consequences of inflammation that might occur in someone with Crohn's disease, including things like strictures, fistulas, abscesses, and perianal inflammation causing abscesses and fistulas.

But it can also impact other areas of the body, the underlying condition of autoimmunity. What are some of those other conditions that can be associated with Crohn's, and specifically the incidence of colorectal cancer?

THOMAS ULLMAN: The extra intestinal manifestations come in a variety of areas, some seemingly bizarre, right? We can get mouth sores-- maybe not so bizarre-- joint inflammation, eye inflammation, loss of protein in the gut, as was mentioned, not quite. But that can have other consequences too, including malnutrition. And the chronic inflammation, as you alluded to, the chronic inflammation, particularly when Crohn's disease involves the large intestine, can give rise to an increased risk for the development of colorectal cancer.

And then how do you think about treatment? We've had different strategies in the past, as we were talking about prior to the show, in terms of the rheumatologists, of treat to target. How do we manage symptoms? So patient comes in. They're referred to you, gastroenterologist. What's your approach to treatment? Is it still a step approach in terms of starting with certain agents? Or you go with the big guns to begin with? What's your approach?

The more inflammation you have, the more intensive the therapy needs to be. And whereas, in the past, we like to do this stepwise approach and use periodic courses of corticosteroids, corticosteroids are out, right? They are wonderful at putting out fires, perhaps, and treating acute inflammation, but so bad and with so many negative consequences in the long term that we do everything we can to minimize their use. And I think that the gastroenterology and IBD community has really gotten around this idea of treating to target, getting rid of the inflammation when it's there, and keeping it away, and using more intensive therapies sooner in the course of disease.

Let's go over these class of therapies. So you mentioned steroids are out. We thought about them before. Maybe different in a flare up or another situation. So patients come to you. How do you manage it in terms of classes of therapies?

So I'd say there's different buckets here. One would be something that's not recommended with Crohn's disease is the mesalamines class, right, but very popular because they're considered nonimmunosuppressing and their oral. There's the immunomodulators, and we have three different classes of biologics, including the antitumor necrosis factors or TNFs, the anti-integrins, such as vedolizumab.

And then we have the anti-interleukins, like IL 12, 23, such as ustekinumab. And a newer one on the market even just this last year, the IL 23 focus, which is risankizumab. Hopefully, in the next year or so, there will be even a small molecule available for Crohn's disease.

So there's lots of options. So how do you work with the patient to decide what's right for them?

So it's really a mutual decision-making process. As the physician, I work to explain to them, this is what I see, OK? I think that you're mild, moderate, severe based on your symptoms, based on your scans and your inflammation. And I am worried that you are at a potential risk for a complication, such as surgery, hospitalization. And then also, this is how you feel, so we want to make that better. And then we'll go through the options. There's not one algorithm for everyone.

And there are risks and benefit.

Yes.

Every drug has that.

Absolutely, absolutely. And then, based on the severity and then also what the patient feels they are willing to accept, that's where we join that decision-making process.

So how do we help patients become good advocates for themselves, to talk about that, based on their symptoms, maybe the current treatment isn't working or a treatment that they have is causing a side effect? How do you have that discussion? Then Dr. Ullman, do you ask them to keep a journal? Do you give them surveys to understand their symptoms? What's the approach that listeners should know, if they have Crohn's or a loved one has Crohn's, to make sure that they're getting the best treatment for them at their stage of disease?

I try and foster as open and honest and environment as possible when I'm seeing patients, but there are enormous challenges that are there. There are social determinants of health that we're really just beginning to unlock at Montefiore and elsewhere in terms of how that impacts on perception of disease and disease itself and when people seek out extra care and when they don't.

How do they know when to seek out extra care?

So I think a lot of that has to do with individual psychological makeup, for lack of a better expression. Some patients are wonderful at suppressing everything, and they never seek out care. And they're just going to tough it out themselves.

We're trying to discourage that though.

And we're definitely trying to discourage that?

How do we do that?

I think that symptom diaries are a great way. I think because of the ease with which it's done, that fecal calprotectin test that Dr. Chang mentioned before, which is just a simple stool test and can alert us to an oncoming flare before it actually gets to become symptomatic, these are tools that we're beginning to understand how they can impact it. But really, openness, honesty, reminding patients that there's a team of support for them in our offices, reminding patients not to tough it out themselves and to rely on friends, family. You can't always do it by yourself.

What about support groups because it can be hard to get a hold of the doctor? Should we be recommending support groups to patients as well?

I think it doesn't have to be a support group. It could be a support system within your friends, family, and close contacts. We've had great success, I think, with our patients in terms of looking on the social media avenues. Some of my patients met other like individuals who had the same surgery, let's say, on Tik-Tok or Facebook. And so that's been immensely helpful psychologically.

Well, doctors, I want to thank you for taking the time today to talk about how do we diagnose and treat Crohn's as well as help patients become their best advocate.

Thank you.

Thanks.

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