Questions Answered By Expert
Christina Ha, MD
Director of the Inflammatory Bowel Disease fellowship at Cedars-Sinai Medical Center, Associate Professor
A: Thanks for the question – monitoring while on medications is important as we can sometimes pick up on subtle changes and act on them before they become a problem. Balsalazide is generally a very safe and well tolerated medication and doesn’t require strict monitoring like some of the other medications. We do recommend checking kidney function through bloodwork at least every year with something called a metabolic panel or profile. This is because there is a rare condition called acute interstitial nephritis associated with this class of medications – I have to emphasize that this is really uncommon, but it’s simple enough to check kidney function annually with blood work, especially if you are taking other medications that can affect the kidneys or have conditions affecting the kidneys (but you are probably already being monitored for that already. With respect to azathioprine, we do recommend getting routine bloodwork – depending on how long and how stable the dosing regimen has been, it can be every 3-6 months. In my practice, I check a CBC (complete blood count) to monitor the White blood cell count number, which can occasionally be low while on the medicine; the Hemoglobin/Hematocrit (which helps us look for anemia), and the platelets which are a subtle and non-specific marker of inflammation. I also check what’s called a complete metabolic profile to check kidney and liver tests, azathioprine can sometimes increase the liver numbers, so we monitor that as well. Also, we recommend at least annual skin exams while on azathioprine, sun protection and to reapply given the association with an increased risk of skin cancer. hide answer
A: My first thought when reading this is that you may have active Crohn’s disease as oral aphthous ulcers tend to be present during active disease. The first thing I would recommend is to get an evaluation of your disease activity. In terms of addressing the symptoms, mouthwashes or rinses that contain steroids and analgesics such as viscous lidocaine are temporizing measures but treatment of the underlying issue is the key. If there isn’t active Crohn’s disease, other causes can be vitamin/mineral deficiencies – zinc, iron, b12, etc, or viral infections or other autoimmune conditions such as Behcet’s disease. However – I suspect that your Crohn’s disease isn’t as well controlled as it should be and would recommend an evaluation, particularly if you are this symptomatic. hide answer
A: It depends on how “normal” the levels are – during active disease, sometime patients require higher dosing and adjustments to still keep them therapeutic. For example, therapeutic is a value > 5, but if someone is symptomatic with a level of 6, they may do better with higher dosing or shortened intervals. If the levels are an acceptable level and there is active disease, then this means that he likely lost response to Remicade/MTX combination – meaning, in simple terms, that his Crohn’s disease outsmarted the medications and he would potentially be better with a medication that works in a different mechanism of action such as vedolizumab (Entyvio) or ustekinumab (Stelara). However, discuss this with your gastroenterologist first. hide answer