By Kimberly Weaver, MD, as told to Stephanie Watson
I am fortunate to work as a gastroenterologist at a time when we have many excellent options for treating Crohn’s disease, including new biologics and small molecule drugs. The number of new treatments researchers are studying in clinical trials makes me even more hopeful about the prospects for people with this chronic inflammatory condition.
Choosing the right treatment
The treatment of Crohn’s disease is very personal. I always try to involve my patients in the decision-making process. When choosing a drug, I take into account its effectiveness and safety. I also think about things like:
- The age of the person
- Their overall health
- Whether they also have skin and joint disorders
- Where and how severe their intestinal inflammation is
- Whether they have strictures or other complications of Crohn’s disease
We also talk about their values, such as whether they prefer to take medicine as an injection at home rather than as an infusion in the hospital.
The goal in treating Crohn’s disease is to improve symptoms and quality of life and prevent complications. We usually use a ‘treat to target’ strategy. That means we try to clear up both the symptoms and the inflammation to put the disease into remission.
Biological medicinal products
Biologics are medications we prescribe for moderate to severe Crohn’s disease. These are large proteins made from living organisms. They target the specific processes in the body that cause inflammation.
There are several classes of biologic drugs approved for the treatment of Crohn’s disease. Each works against a different protein that causes inflammation.
We have medications that inhibit the tumor necrosis factor (TNF) protein, 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 prevents white blood cells from entering the intestines
Biosimilars are virtually identical copies of biological drugs that have already been approved. They have the same effectiveness and safety as the originally approved biologic therapy for people with Crohn’s disease. They contain:
- Infliximab-abda (Renflexis)
- Infliximab-axxq (Avsola)
- Infliximab-dyyb (Inflectra)
Surgery has always played an important role in the treatment of Crohn’s and can be lifesaving. But thanks to these newer medications, the number of surgeries appears to be decreasing. Our medications better control inflammation, 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 armamentarium of therapies has expanded. We try to identify biomarkers – substances in someone’s blood – that will help us find the right treatment for them.
We have learned that some people with Crohn’s disease carry a genetic marker called the human leukocyte antigen (HLA) DQA1*05 allele. This could put them at high risk of forming antibodies against anti-TNF biological drugs. That can make these medications less effective.
If we know someone carries this marker, we often use combination therapy with a biologic anti-TNF drug plus an immunomodulatory drug. Or we use a biological medicine that is not against TNF as the first treatment.
It is not our standard practice to check for this mark as insurance may not cover the cost. But in the future, taking a blood test to check these or other markers could help us choose the treatment that works best for a particular patient.
Why I’m optimistic
This is an exciting time to treat Crohn’s disease. We have made great progress in both the diagnosis and treatment of this disease. And we have become better at preventing complications.
There are many drugs in development for Crohn’s disease, some of which have new therapeutic targets. Some of these are pills, including:
- The sphingosine-1-phosphate (S1P) receptor modulator ozanimod (Zeposia)
- The selective Janus kinase (JAK) 1 inhibitor upadacitinib (Rinvoq)
That’s exciting because people can take them by mouth instead of having to go to the doctor for an IV or give themselves an injection.
I’m also pleased 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 – head-to-head studies have shown that IL-23 inhibitors are more effective than ustekinumab (Stelara) and adalimumab (Humira).
Remaining challenges
As with most other long-term 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, and environmental and lifestyle factors play a role in causing it.
There are also many different types of Crohn’s disease. Someone who only has inflammation in the small intestine is probably different from someone with inflammation in the large intestine. Some patients have a very mild course of the disease. Others have a very serious condition and develop complications such as strictures or fistulas. Unfortunately, no magic pill can treat every form of the disease.
Another problem is the high treatment costs. Biological medications can be very expensive. Depending on insurance coverage, a single treatment can cost thousands of dollars.
We need to make these medicines more affordable so that they are accessible to everyone. Although I strive to provide my patients with the best care possible, insurance companies often deny coverage for biologics. This also applies to treatments that my patients have been undergoing 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 on a cure and, ultimately, a way to prevent this condition.
Clinical trials provide people with Crohn’s disease with access to new and emerging treatments. To learn more about clinical trials, talk to the gastroenterologist treating your Crohn’s disease or visit the Crohn’s & Colitis Foundation website.