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Lilani Perera, MD

Gastroenterologist

Q: Just diagnosed with moderate Crohn’s disease in small bowel with narrowing in terminal ileum. My main complaint is abdominal pain. The doctor wanted to put me on 40 mg of Prednisone for 2 weeks but I’m a chicken (ha) so I choose Entocort. It’s been 5 days and I still have horrible stomach pains and some back pain. Can I switch over to prednisone without problems?

A: Degree of response to medicatherapy of crohn’s stricture/narrowing depends on amount of active inflammation vs scarring/fibrosis. Current medical therapy is not effective against fibrosis but will decrease inflammation resulting in opening/decreasing the narrowing of your terminal ileum. Entocort 9 mg is usually very effective but you can try switching it to prednisone to see if you have better response. I would also recommend obtaining abdominal imaging such as CT enterography or MR enterography to better define the extent (more stricture event tight ones) and severity of small bowel disease. If it is moderate disease you will benefit from biologic therapy with or without immunomodulator to induce remission and maintain remission. Staying on low residue diet will also decrease your abdominal pain if it is related to sluggish passage of material through the narrow terminal ileum. If you have critical/severe narrowing with dilation of bowel before/proximal stricture, you may need surgical intervention in near future. hide answer

Q: I was diagnosed with Crohn’s in 1998 and then diagnosed with fistulizing Crohn's in 2000 after a major surgery. I started Remicade in 2001. It has kept me in remission and fistula free until last year. I recently became aware that for the past year I have been getting Inflectra, not Remicade. Could this change in medication contribute to the development of fistula? Is there any research about the changes patients have when switched from the original biologic to a biosimilar?

A: There are multiple studies showing equal efficacy of Inflectra to its originator Inflximab. More important question in your situation would be the adequacy of the drug level as well as presence of antibodies against the drug. I would recommend performing therapeutic drug monitoring to get this information if this has not been done before. When was the last time you had colonoscopic evaluation or abdominal imaging to objectively assess the treatment response while you were still on Infliximab? If it is few years ago, it is possible you had partial controlled disease for some time (while you were on Infliximab) prior to developing the new fistula. If this is the case as mentioned before, therapeutic drug monitoring will help you to figure out what could be the best possible therapeutic change to get your disease under control again. If you have perianal fistulizing disease, MRI of rectum will better define the disease and examination under anesthesia with seton placement will facilitate the healing with correct medical therapy. hide answer

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