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BACKGROUND


CROHN’S DISEASE


As noted above, CD is a chronic (ongoing) disorder that causes inflammation of any area of the GI tract from the mouth to the anus, although it most commonly affects the small intestine and/or colon. The symptoms and complications of CD differ, depending on what part of the intestinal tract is inflamed. CD is classified as mild, moderate or severe based on the age at diagnosis, the location of the disease, and the disease behaviour (penetrating and/or stricturing [scarring] or neither).2


Symptoms


Persistent diarrhea (loose, watery, or frequent bowel movements), crampy abdominal pain, fever, and, at times, rectal bleeding are the hallmark symptoms of CD, but they vary from person to person and may change over time. Loss of appetite and subsequent weight loss may also occur. However, the disease is not always limited to the GI tract; individuals may experience symptoms outside of the intestine, which may affect the joints, bones, eyes, skin and liver. Fatigue is another common complaint. Children who have CD may suffer osteoporosis, and may fail to develop or grow properly.


Some patients may develop tears (fissures) in the lining of the anus, which may cause pain and bleeding, especially during bowel movements. Inflammation may also cause a fistula to develop. A fistula is a tunnel that leads from one loop of intestine to another, or that connects the intestine to the bladder, vagina or skin. Fistulas occur most commonly around the anal area. If this complication arises, the patient may drain mucus, pus, or stool from this opening.


Symptoms may range from mild to severe. Because Crohn’s disease is a chronic but fluctuating disease, patients will go through periods in which the disease flares up, is active, and causes symptoms. These episodes are followed by times of remission – periods in which symptoms disappear or decrease and good health returns. In general, people with CD lead mostly full, active and productive lives.


Treatment Options


People with CD in Canada are treated in step-wise approaches – the traditional “step-up” or the newer “top-down” approaches. The “step-up” approach treats patients with corticosteroids during periods of disease flare, to reduce symptoms and induce remission. These drugs are not generally taken on a long-term basis. For long-term control, immune modifiers are typically initiated.


If patients have tried one or two different immune modifiers and doses have been maximized yet they still have problems or cannot tolerate these agents, then biological therapies are tried.3 In the “step-up” sequence, biologicals are reserved for later use because they are the most expensive of the drugs available. Patients with fistulizing disease may start a biological therapy early, because other drugs are not effective. Best practices for the use of biologicals are still being defined, and there may be a variety of current practice patterns. For example, some researchers and clinicians now think that it may be worthwhile in selected patients to try these drugs early in a “top-down” approach since they can be very effective and they could change the course of the disease, by reducing bowel damage and eventual surgery.


THE IMPACT OF INFLAMMATORY BOWEL DISEASE IN CANADA 19


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