Expert Q&A

A: If you think that the symptoms of fatigue, dizziness, and weakness may be due to the methotrexate, I recommend discussing possibly stopping the medication with your doctor. Methotrexate is often used to prevent antibody formation to Remicade, and your doctor can advise you whether you may be able to try Remicade on its own, or possibly with an immunosuppressant from a different class of medications that may not cause the same problems for you. However, you also make a very good point that it is important to find out if your intestine is healing on your current medication regimen. Some of your symptoms, such as fatigue, could also be caused by ongoing inflammation. Your doctor may do testing include a stool test for calprotecin (a marker of inflammation), a colonoscopy, or a MRI or CT scan to help determine if the intestine has healed. hide answer

A: It is very important that your husband has been tested for TB prior to starting a biologic, since if TB were present and inactive, it could become re-activated on biologic medications. You are correct that your husband’s TB test may be resulting as “indeterminate” because of his immunosuppressant. Going to the infectious disease specialist seems like a good way to be sure. If the doctor does find evidence of latent TB, then anti-bacterial medications to treat the latent infection, such as Isoniazid, may be prescribed. Once the treatment for latent TB has been started, patients are able to proceed with their biologic treatment for Crohn’s. hide answer

A: I would consider your GI symptoms along with colonoscopy findings showing ulcers as indications that your Crohn’s is active (you could call that either a flare or recurrence, I think both are the same in this case). Entocort (budesonide) is a steroid, and should only be used as a short term treatment to induce remission. It should not be used long term to maintain remission. It sounds like you should discuss starting a more long term medication to treat your Crohn’s with your doctor, either an immunosuppressant or biologic. I think it is important to do this soon so that your disease does not continue to progress---we do not want you to need another surgery down the line. hide answer

A: Remicade has 3 “loading doses” during which time you are getting to the right level of drug in your system. The drug is dosed at week 0, 2, and 6 initially. Sometimes patients will need a longer period of overlap with steroids and Remicade in order to give the Remicade more of a chance to work. Or, sometimes your doctor may need to adjust the amount of Remicade you are given during the infusion. Also, it will be important to work with your doctor to find out why the pain is occurring—if it is due to the active inflammation in the intestine, a narrow area, scar tissue, or maybe something else. Not all pain is caused by active inflammation, so it is important to know why it is happening so that the correct treatment can be chosen. hide answer

A: Stretching of an anal stricture can sometimes be done via flexible sigmoidoscopy (a short scope into the bottom of the colon). However, some sort of bowel prep would likely be necessary. There are several different options of bowel preps, so perhaps your daughter can work with her doctor to find one that is easier for her to tolerate. In terms of her medication regimen, it sounds like changing medications would be a good idea. Entocort (budesonide) is a steroid medication, and should only be used for a short time to help induce remission, but should not be used as a long term maintenance medication. Also, it is targeted to the end of the small intestine (terminal ileum) and right side of the colon, and is likely not helping the anal stricture area. Apriso is FDA approved for mild to moderate ulcerative colitis, and is likely not effective for Crohn’s disease that is causing strictures. Biologic medications such as the ones you have mentioned are effective for moderate to severe Crohn’s that has failed to respond to other medications. Remicade and Humira are both antibodies directed again TNFa, one part of the overactive immune response that is attacking the intestine. Remicade is given as IV infusions, 3 times in the first 6 weeks, and then every weeks. Humira is a shot every 2 weeks. Stelara is an antibody against two chemicals involved in the immune response, IL-12 and IL-23. It is given as a one time IV infusion, and then a shot every 8 weeks. All are effective, and your daughter’s doctor may be best able to discuss the risks and benefits in her particular situation. hide answer