Article-Crohn's Disease: Advances in Treatment

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Crohn's Disease: Advances in Treatment

R. Lichtenstein, MD P. MacDermott, MDIntroduction

Inflammatory bowel disease (IBD) encompasses 2 distinct chronic, idiopathic inflammatory disorders that affect the gastrointestinal tract: Crohn's disease and ulcerative colitis. Although these 2 entities are frequently grouped together, it is important to appreciate their inherent differences because they may have a profound impact on medical and surgical management.

The incidence of Crohn's disease and ulcerative colitis in the United States is approximately 5 and 15 per 100,000 persons, respectively. There is evidence that the incidence of Crohn's disease has increased worldwide during the past several decades, although this rise appears to have plateaued during the last 10 years. The incidence of ulcerative colitis remains fairly constant. The prevalence of these diseases is estimated to be 90 per 100,000 persons for Crohn's disease and 200 per 100,000 persons for ulcerative colitis. The annual medical cost for the care of patients with IBD in the United States is considerable and has been estimated to be $1.6 billion (in 1990 US dollars; $1.1 billion for Crohn's disease and $0.5 billion for ulcerative colitis). When adjusted for loss of productivity of patients, the total economic cost is estimated to be $2.2 billion.

Medical therapy has remained the mainstay of treatment for patients with IBD. Despite our aggressive approach to medical therapy in patients with IBD, surgery is still required in approximately three quarters of patients with Crohn's disease and one quarter of patients with ulcerative colitis. Individuals who have refractory disease, precancerous lesions, cancer, intestinal strictures, pyogenic complications, and symptomatic fistula are historically those who undergo surgical intervention. The goals of medical therapy for IBD include induction of remission in patients with active disease and maintenance of remission in those with quiescent disease that is either medically or surgically induced, while improving the patient's quality of life.

Based on our current understanding of the pathogenesis of these disorders, therapies have been focused on attenuation of the enteric immune response and inflammatory process. Conventional therapies, such as aminosalicylates and corticosteroids, continue to be widely used. Newer agents (eg, balsalazide, budesonide) in these particular classes, mesalamine derivatives and corticosteroids, hold promise for enhanced efficacy and/or tolerability. During the past decade, immunomodulators have become an integral part of the armamentarium for clinicians in the management of IBD. The recent introduction of biologic therapies offers exciting potential for additional therapeutic benefit. Among these novel agents, infliximab has become a standard therapy for patients with Crohn's disease. None of the currently available therapies, however, is ideal. Continued efforts in the search for superior drugs are still needed. This report focuses on advances in Crohn's disease as recently presented during the annual meeting of the American College of Gastroenterology (ACG).