Patients with steroid-dependent Cro...

Patients with steroid-dependent Crohn's disease are those who answer to steroid therapy but cannot taper the treatment. Steroid-refractive patients are those who fail to answer to adequate treatment dosages of up to 1 mg through kg of prednisone within four weeks. Steroid adjunct is common in patients with Crohn's disease who correspond to prednisone treatment. Contributing factors associated with steroid colony include cigarette smoking, nonsteroidal anti-inflammatory remedy use, Clostridium difficile infection, and united irritable bowel or chronic pain syndrome Hanauer reviews the management of patients with steroid-dependent Crohn's disease.

Symptoms should be evaluated to command out visceral hypersensitivity or malabsorption, which can masquerade as inflammatory disease. Initial investigation should include a perfect blood count; determination of sedimentation rate or C-reactive protein level; and stool examination for leukocyte or lactoferrin, enteric pathogens, and C difficile toxin. Radiographic studies or endoscopy may be useful for identifying fixed-stenoses, evidence of small bowel stasis, or short-segment disease. In patients with diarrhea, laxative abuse and other forms of surreptitious diarrhea should be exclud Fecal fat analysis may reveal sensitivity to dietary fat intake.

Management strategies for steroid-dependent patients include surgery (if the patient has a short-segment disease, especially with evidence of stenosis) and immunomodulator therapy. Surgery potentially can restore health to a fiercely ill patient. Immunomodulator therapy with azathioprine or 6-mercaptopurine has been studied principally frequently in combination with prednisone. Although combination therapy has one therapeutic advantage, the efficacy of these agents in steroid-dependent patients is unclear. Methotrexate and infliximab appear to be more felicitous in weaning patients from steroid prop Other agents such as mesalamine appear to have no use in tapering steroid-dependent patients.

The author judges that patients with steroid-dependent Crohn's disease are best helped at reassessing the causes of the symptoms, eliminating potential exacerbating factors, employing surgery in chosen patients with localized disease, and using azathioprine or mercaptopurine. With the latter therapy, one time patients are weaned from steroids, the purine antimetabolite is continued for an indefinite period while the physician monitors white vital current cell count and liver enzyme If purine metabolites cannot be used, methotrexate or infliximab can be tried. Patients who are refractory to steroids and immunomodulators and patients in whom steroids are contraindicated should be given infliximab for an indefinite period.

Hanauer SB Considerations in the management of steroid-dependent Crohn's disease. Gastroenterology September 2003:125;906-10

EDITOR'S NOTE: Guidelines from the American corporation of Gastroenterology (1) discuss the management of Crohn's disease in adults. Presenting symptoms of Crohn's disease can include chronic diarrhea, abdominal pain, intestinal obstruction, weight los excitement and night sweats. The differential diagnosis includes other inflammatory or idiopathic bowel disorders and irritable bowel syndrome The impact of stres forward symptoms is unclear. Disease activity is ranked depending onward symptoms and the negative impact forward a patient's quality of life. Therapy should consider treating the disease first and then keeping the patient in remission.

Patients with moderate to inexorable disease can be treated with prednisone in a dosage of 40 to 60 mg daily until symptoms interpret and weight gain resumes. Infliximab is a useful adjunct or alternative to corticosteroid therapy when the latter cannot be used or is ineffective. Because of the negative general intents of chronic steroid use, an alternative agent should be used to maintain long-term remission. Azathioprine and mercaptopurine can be helpful after remission has been achieved with steroid therapy. In patients who have had ileocolonic resection, mesalamine, azathioprine, or mercaptopurine may help decrease the incidence of recurrence--RS

REFERENCE

(1) Hanauer SB Sandborn W Management of Crohn's disease in adults. Am J Gastroenterol 2001;96: 635-43

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