Expert Q&A

A: This is a very common question. In my practice, we stress the importance of shared decision making between the physician, the parents and the most importantly, the patient. When selecting a new medication, it is key to be completely informed. As both adalimumab (Humira) and infliximab (Remicade) target the same inflammatory protein (TNF-alpha), their efficacy (remission rates) are essentially equal for Crohn’s disease. In addition, the safety profile are similar. How are they different. Adalumumab is given as an injection (typically in the lower abdomen or upper thigh) at home and infliximab is given as an infusion requiring an intravenous (IV) catheter with each dose. Adalimumab is injected every 2 weeks (although some patients require weekly dosing). The first 3 doses of infliximab (induction) are given over 6 weeks with maintenance doses given every 8 weeks (some patients may require infusions every 4-6 weeks). Infliximab infusions require outpatient visits at infusion centers with the infusion lasting 1-3 hours. Factors to consider between the two: convenience (home vs. infusion center) and patient preference to medication delivery (injections vs. IV starts). At our center, all patients starting infliximab receive the first 5 doses over 3-hours at our infusion center. If the infusions are well-tolerated, we provide the option of receiving those infusions over 1-hour and at the patients home with a nurse from the home health agency. hide answer

A: Whenever a parent is ill, it is natural for a child to be concerned about their own health. Although we know a family history of Crohn’s may increase the risk of Crohn’s disease in their children, it is also important to know that many of the signs and symptoms that are associated with Crohn’s disease are also shared with other illnesses, such as gastrointestinal infections (bacterial or viral causes), irritable bowel syndrome (IBS) or Celiac disease. In my practice, it is common to see siblings or children with a family history of Crohn’s disease and find out (by examination or testing) that the primary symptoms are secondary to another cause and not Crohn’s disease. In your situation, it is important to discuss these symptoms with your parents so they can make an appointment with your regular doctor. Your doctor will carefully listen to your symptoms, check your growth (height and weight), perform a physical exam and potentially order blood or stool tests to determine the cause. The sooner a diagnosis is made, the faster a treatment can be offered. If any of the symptoms are concerning for Crohn’s disease, your doctor will make an appointment with a gastroenterologist, a doctor specialized in diagnosing and treating Crohn’s disease. It’s really important to know that in the present day (2020), there are many more medication and dietary options to better manage Crohn’s disease than were available to previous generations. I tell each patient newly diagnosed with Crohn’s disease, that regardless of the ups/downs or curves in their road to recovery, our goal is to find the best treatment that puts them back on a straight path toward achieving all their personal goals! hide answer

A: While the cause of the inflammatory bowel diseases (IBD, ulcerative colitis and Crohn’s disease) is multifactorial, the current data suggests the absolute risk for UC is 1.6% with maternal UC and 2.7% with maternal Crohn’s disease. If both parents have IBD, then the overall risk is increased. It is important to discuss family planning with your gastroenterologist as there are some medications that may need to be stopped or changed prior to becoming pregnant. While there is so much more to learn about the risks of developing IBD, we do know the three main components are (1) genetic, (2) environment exposures and intestinal microbiome and (3) an inappropriate immune response. For IBD to develop, it’s a combination of the perfect storm of all three components. It’s natural for parents/patients to ask what they can do to prevent IBD in their own children? The latest data would suggest that environmental triggers that increase the risk of IBD are (a) exposure (active or passive) to cigarette smoking (b) increased use of antibiotics, (c) increased use of nonsteroidal anti-inflammatory drugs (NSAIDS like ibuprofen) and (d) consuming a westernized, highly processed diet. The current data also suggests that the key to optimal the best outcomes (child or adult) is recognizing (awareness) the symptoms of IBD, early diagnosis and timely treatment. hide answer

A: Although the diagnosis of ulcerative colitis or Crohn’s disease can be difficult for any patient at any age, it is important to recognize that depression and anxiety are extremely common when the diagnosis occurs during adolescence and young adulthood. At our center, we offer every child/young adult the opportunity to meet with our IBD-focused psychologist. We find that young patients really need an outlet to express their feelings as our behavioral specialists focus on teaching techniques to cope with the disease. Whether it’s use of guided imagery or deep breathing, coping is a learned behavior that young patients may not initially intuitively recognize or take the time to practice. It’s important to recognize when to ask for help with a psychologist or psychiatrist, even if your treatment center doesn’t have access to an IBD-focused psychologist. Adalimumab (Humira) is a medication that binds to a protein in the body called TNF-alpha. The multiple studies in adults and children have shown that it not only heals the intestinal tract, but also improves growth by improving gut absorption of key nutrients and improving the overall quality of life for the patient. It is classified as an immune-suppressing medication. While the use of this medication can be associated with an increase risk of certain infections, this is uncommon. Prior to starting, your doctor will check for an active TB infection and may check for active intestinal infections or fungal infections. The additional risks such as an allergic reactions to the injection, rashes, liver injury, and certain cancers are also very low. It’s important to discuss the specific risk/benefits with your doctor so they can tailor the treatment to your needs. hide answer

A: Crohn’s disease can certainly impair bone health as all patients are at an increased risk of nutrient deficiencies (Vitamin D, Vitamin B12, zinc, iron and folate). Moreover, some Crohn’s disease patients may restrict their diets (such as dairy-free, lactose-free) to control symptoms, and therefore, can further exacerbate the risk of poor bone health by limiting both Vitamin D and calcium. For your 17 year-old son, it would be important to keep a 1-2 week diet history to further review with your gastroenterologist or registered dietician to better understand if his current diet is lacking specific nutrients. Given the history of poor bone health, he may require additional Vitamin D and calcium depending on this diet history. In my practice, we check Vitamin D every 6 months (supplement when needed) and check a bone density at the time of diagnosis and repeat if needed (such as following recurrent fractures or more severe disease). While clinical remission (no active gastrointestinal symptoms) is an important goal, we now recognize that complete gut healing is even more important in order to prevent further complications of Crohn’s disease. It is reasonable to review your laboratory markers with your doctor and ask if further testing is needed (endoscopy or abdominal imaging). In regards to the medication, we typically find that the infliximab (Remicade) improves intestinal absorption of key nutrients by healing the gut. As each patient requires personalized care for their IBD, I would recommend discussing potential medical side effects with your primary gastroenterologist as well. hide answer