A patients perspective on living with Crohn’s Disease, by Nigel Horwood
- Crohn’s is a chronic, inflammatory disease affecting the digestive tract and the incidence is on the increase
- Treatment options have come a long way but as yet there is no cure so attaining remission is the primary goal
- As we make real progress treating the disease we must continue to work hard to improve support, acceptance and address the mental health aspects of Living with Crohn’s
The Past - Conventional Drugs
When I was diagnosed with Crohn’s Disease, in the late 1970s, treatment options were simple. There was – salazopyrine (a disease-modifying anti-rheumatic drug), prednisolone (a corticosteroid) and codeine phosphate (an opioid analgesic). With no internet, the only sources of information about both the condition and treatment were your consultants or medical books. The disease was not widely known about by the public or GPs, and the concept of being an “informed patient” was unheard of.
If you were lucky, and I was lucky – mostly, the drugs would kick in, the inflammation in the gut would be reduced. You might even go into remission. I did have a temporary blip when my bowel perforated and I had the chance to experience the alternative treatment option – surgery.
With the advent of the internet, patients were able to be much better informed. At this point I had been taking steroids continuously for over 20 years. I read about their potential side effects and asked my gastroenterologist if there was an alternative. A barium meal x-ray showed that I had a stricture near my terminal ileum that had reduced the lumen down to the size of my little finger. The choices were stark. Either go for surgery or try, as a “final resort”, azathioprine – a chemo drug, an immunosuppressive therapy from the world of transplants. There would be the inherent risk of side effects but I was adamant I wanted to avoid surgery so opted for the drug.
The treatment worked well and brought with it 9 years of virtual remission, then a routine blood test showed that my platelet count had dramatically fallen. I had succumbed to one of the known side effects – bone marrow suppression – and the drug was stopped. A CT scan showed that the stricture was as bad as ever but now there were internal fistulas interconnecting loops of the bowel. The gastroenterologist said “it looks like you’ve got an octopus in there”.
(CT scans are now being widely replaced with MRI scans which can provide the ‘cross-section’ anatomical detail but without the ionizing radiation of the former.)
Magnetic Resonance Imaging of the small intestine showing the bowel moving. A stricture can be seen in the middle of the screen, above the bladder.
I was now resigned to surgery so was surprised to be offered a final “final” resort in the form of Infliximab (Remicade), a monoclonal antibody. I had not heard of this new class of drugs that work to reduce inflammation by targeting proteins in the immune system. This particular one, introduced in 1998, had been identified as good at healing fistulas. In all honesty I think my condition was too far advanced to be treated by any drug and after the initial “Infliximab high” I was getting progressively worse. The drug, delivered by infusion, was stopped after the third dose. In late 2010 I went into the operating theatre, for the second time in my life, to finally have the stricture removed. I had been warned that a temporary stoma was a possibility in order to give my gut a chance to recover. When I woke up post-operation I now had a “bag” which remained in place until July 2011.
Following surgery it is common to be given a maintenance dose of Azathioprine. In my case it was not an option but as the follow-up colonoscopies showed no sign of inflammation I took no Crohn’s drugs at all.
Rise of the Monoclonal Antibodies (MAbs)
When I encountered monoclonal antibodies in 2009 they had already been in use for a decade. In the following years there has been a great deal of research work ongoing for their use in multiple areas of medicine and many have subsequently been licenced to treat Crohn’s. However they are neither cheap to develop or manufacture and each dose is expensive when compared to more traditional medicines.
A number of the original MAbs, Remicade for instance, are now out of patent which has led to a range of “biosimilars” being produced. Whilst the cost of development, approvals and manufacture is still high the NHS can make considerable savings over the original drugs. Some patients have voiced their concern about switching over from their regular prescription to the corresponding biosimilar.
Once treatment commences there is a finite period before its effectiveness can be gauged. The clearest indication will be the patient finding that their symptoms are improving but the situation is more complicated for those that are asymptomatic. A formal monitoring regime may consist of regular faecal calprotectin test (FCP) tests three months after the start followed by a colonoscopy and MRI at twelve months. (The timings will vary depending upon the treatment being used). These two procedures are complementary. The colonoscopy enables the consultant to assess the internal surface of the gut wall and take biopsies as required; the MRI scan can see any extramural disease or thickenings.
My own encounter with MAbs did not end with Remicade. In 2016 a routine FCP showed an elevated level. This indicates that there is active inflammation somewhere in the gut. It was a surprise as I was feeling no symptoms. My gastroenterologist decided to investigate with the combination of a colonoscopy and a small bowel MRI scan.
Neither test showed anything untoward. I was happy to continue drug free and accepted that the raised FCP level must be an anomaly.
Further, regular FCP tests showed an upward trend continuing but I still felt very well with a good QOL. In late 2018 I thought we really should do some further investigation and asked to have the one procedure that I had never experienced – a capsule endoscopy. When the results came back it showed moderate inflammation in the small bowel. After discussion with my gastroenterologist we decided that I should start Entyvio as it was the most suited to my particular circumstances.
I have now completed the first three “loading” doses. Is it working? The simple answer is – I don’t know. I feel no different from after my reversal operation. The monitoring plan for FCP and, after one year, another colonoscopy and MRI scan. Meanwhile I get a trip to London every two months for the infusion which is followed by a virtual clinic reviewing my progress.
The IBD market, as a whole, has been identified as a growing commercial opportunity so expect to see a wide range of new or improved treatments being rolled out by pharmaceutical companies. Ultimately the goal is to find a “cure” but in the meantime the focus is on developing treatments more targeted to specific areas of the gut thereby reducing the side effects caused by generalised anti-inflammatory drugs. Other areas are also being explored, including stem cell therapies. Two currently undergoing trials are :
Cx601 – specifically aimed at healing perianal fistulas, a very distressing condition that may result in patients undergoing extremely serious and life changing surgery. Cx601 is administered as a single injection given by a colorectal surgeon.
Stem Cell Transplant – currently trialing with a small number of Crohn’s patients. They undergo chemotherapy and hormone treatment to mobilise their stem cells, which are then harvested from their blood. A further round of chemotherapy then wipes out their faulty immune system. When the stem cells are re-introduced back into the body, they develop into new cells which give the patient a fresh immune system that will no longer react adversely to the patient’s own gut.
Advances in treatment are being mirrored by improvements in test procedures. Conventional scopes are unable to travel far into the small intestine and are therefore unsuitable for observing small bowel Crohn’s. The capsule endoscopy enables images of the whole of the digestive tract to be recorded. First approved in USA in 2011, it consists of a swallowable capsule containing a camera and a wireless transmitter. Images are recorded on a unit worn by the patient and the results then interpreted by a gastroenterologist. This latter process is time consuming as there are hundreds of frames to assess.
A boom in medical imaging software means that the analysis of images from tests like MRI and capsule endoscopies are becoming quicker using machine learning/AI techniques. Crucially, the software can provide quantitative analysis with the promise of rapid, objective indicators of when treatment is working.
An example of this software is GIQuant, developed by Motilent for use with standard MRI scanners, it quantifies the motility of the gut and gives results in virtually real time. It has the additional benefits of shorter scan times, reduced prep solution and no need for gadolinium-based contrast dye. In many instances it will also replace the need for a colonoscopy.
What direction may future developments take? There is no definitive answer to what causes Crohn’s Disease. A number of factors, such as heredity, a malfunctioning immune system and environmental conditions are thought to play a role in its development. In each patient the mix of these factors will vary. The logical next step will be to produce test that can identify this mix and tailor therapies to the individual patient’s circumstances.
This article has only touched on physical symptoms. Part Two will look at what it is like to live with Crohn’s Disease day-to-day, the potential effects on one’s mental health and some of the therapies being researched to help patients cope.