By Kimberly Weaver, MD, told to Stephanie Watson
I am fortunate to work as a gastroenterologist at a time when we have many great options for treating Crohn’s disease, including new biologics and small molecule drugs. The number of new treatments that researchers are studying in clinical trials makes me even more optimistic about the prospects for people with this chronic inflammatory disease.
Choose the right treatment
Treatment for Crohn’s disease is very individualized. I always try to include my patients in the decision making process. When choosing a drug, I consider its effectiveness and safety. I also consider things like:
- The person’s age
- Their general state of health
- If they also have skin and joint conditions
- Where and how severe is their intestinal inflammation
- Whether they have strictures or other complications of Crohn’s disease
We also talk about their values, including whether they prefer to take medication as an injection at home or an infusion in the hospital.
The goal of treatment for Crohn’s disease is to improve symptoms and quality of life while preventing complications. We generally use a “treat to target” strategy. This means that we are trying to eliminate both the symptoms and the inflammation to put the disease into remission.
Biologics are drugs we prescribe for moderate to severe Crohn’s disease. They are large proteins made from living organisms. They target specific body processes that trigger inflammation.
Several classes of biologics are approved to treat Crohn’s disease. Each acts against a different protein that causes inflammation.
We have drugs that inhibit the protein called tumor necrosis factor (TNF), including:
- Adalimumab (Humira)
- Certolizumab pegol (Cimzia)
- Infliximab (Remicade)
More recently approved biologics include:
- Ustekinumab (Stelara), which works by blocking the proteins interleukin 12 and 23 (IL-12 and IL-23)
- Vedolizumab (Entyvio), which stops white blood cells from moving through the gut
Biosimilars are nearly identical copies of previously approved biologic drugs. They have the same efficacy and safety as the biological therapy originally approved for people with Crohn’s disease. They understand:
- Infliximab-abda (Renflexis)
- Infliximab-axxq (Avsola)
- Infliximab-dyyb (Inflectra)
Surgery has always played an important role in the management of Crohn’s disease and can save lives. But thanks to these new drugs, surgery rates seem to be falling. Our drugs control inflammation better, so they can help people avoid surgeries they may have needed in the past.
Looking for better results
We are trying to better understand which patients will respond best to a specific drug, especially as our therapeutic arsenal has expanded. We try to identify biomarkers – substances in a person’s blood – that help us find the right treatment for them.
We have learned that some people with Crohn’s disease carry a genetic marker called the DQA1*05 human leukocyte antigen (HLA) allele. This could put them at high risk of forming biological anti-TNF antibodies. This can make these drugs less effective.
If we know someone has this marker, we often use combination therapy with a biological anti-TNF plus an immunomodulatory drug. Or we use a biological non-anti-TNF as the first treatment.
It is not our standard practice to check this marker as insurance may not cover the cost. But in the future, doing a blood test to check for this marker or others could help us decide which treatment will work best for a certain patient.
Why am I optimistic
It’s an exciting time to treat Crohn’s disease. We have made great strides in diagnosing and managing this disease. And we have improved in preventing complications.
Many drugs are in development for Crohn’s disease, some of which have new therapeutic targets. Some of them are pills, including:
- The sphingosine-1-phosphate (S1P) receptor modulator ozanimod (Zeposia)
- Upadacitinib (Rinvoq), selective Janus kinase (JAK) 1 inhibitor
It’s exciting because people can take them orally instead of having to go to their doctor for an infusion or get an injection.
I am also delighted that a drug that blocks IL-23 has been approved for the treatment of moderate to severe Crohn’s disease in adults. Risankizumab-rzaa (Skyrizi) was approved in 2022 as the first IL-23 blocker. For the treatment of another inflammatory disease, psoriasis, comparative studies have shown that IL-23 inhibitors are more effective than ustekinumab (Stelara) and adalimumab (Humira).
As with most other long-lasting medical conditions, including high blood pressure and diabetes, we still don’t have a cure for Crohn’s disease. It’s hard to say how far we are from one. Crohn’s disease is complex. A combination of genetic, immune system, environmental and lifestyle factors play a role in its cause.
Also, there are many types of Crohn’s disease. Someone who only has inflammation in the small intestine is probably different from someone who has inflammation in the colon. Some patients have a very mild disease course. Others have a very severe one and have complications such as strictures or fistulas. Unfortunately, no magic pill can treat all forms of the disease.
Another challenge is the high cost of treatment. Biologic drugs can be very expensive. Depending on insurance coverage, a single treatment can cost thousands of dollars.
We need to make these drugs more affordable so that they are available to everyone. Although I strive to provide my patients with the best possible care, insurance companies often refuse to cover biologic drugs. This includes treatments that my patients have been following for several years.
Learn more about Crohn’s disease
Our goal is to develop more effective treatments for Crohn’s disease. We continue to work towards a cure and ultimately a way to prevent this disease.
Clinical trials provide people with Crohn’s disease with access to new and emerging treatments. If you want to learn more about clinical trials, talk to the gastroenterologist treating your Crohn’s disease or visit the Crohn’s & Colitis Foundation website.