Crohn's Treatment and Lymphoma

[finnwalk]

Situation:  My mother is 79 and has had Crohn's for 30 years.  She was recently seen by an oncologist for "possibly" having low-level lymphoma (only way to be sure is thru surgery for tissue biopsy) while at the same time being told by her gastro dr. that Remicade is the only thing left for her to try to control her CONSTANT diarrhea.  She just had a camera capsule study to confirm the Crohn's is very active in the small intestine.  The oncologist told her that Remicade can increase the chances of lymphoma, so if indeed she does have a low-level lymphoma it could worsen.  Are there any other options for treatment?  She has had several periods of prednisone treatment but now has osteoporosis.  The diarrhea has made her housebound, not to mention exhausted and depressed.  Hemoglobin down to 9.5.  Any thoughts?

[Kevin Pho, MD]

Remicade is typically used as a second or third line agent for Crohn's disease.  I would assume that since this is considered, more traditional therapy like steroids are not a feasible option.

Most cases of refractory Crohn's disease are tried on azathioprine and 6-mercaptopurine, with a response rate of 60 to 70 percent.

Methotrexate is also an option for those who don't respond.

Finally bowel rest and total parenteral nutrition can be considered as a last resort.  

These options can be discussed with your GI physician.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Kevin, M.D.
kevinmd_

[lizziecee]

Hi there - I have had chronic Crohn's since I was 25 yrs old, now 62 yrs. Guess I have tried most medications, except Remicade, which my gastro advises against as I also have chronic psoriasis and he said I will get infections at the injection/infusion sites. I have been on methotrexate for some 5 years now, orally initially, but after I got breast cancer in 2003, and had to suspend mtx because I was having FEC chemo. Since then have been on weekly self administered injections. This, coupled with daily codeine phosphate, and recently some antibiotics such as amoxiclav and cipro, have been enough to bring the daily diarrhoea under control. Got my life back again and don't have to wear senior's diaper pads!

I don't know which country you are in, can only tell you what my gastro in the UK prescribes - he is the best, so very committed to IBD - he even worked in a leper colony some years ago.
I hope you can get your mother some relief from her daily dreadful symtoms. I was faecally incontinent in the street when undergoing FEC chemo for breast cancer which was very embarrassing. My Oncologist put me onto small doses daily of dexamethsone as I had a serious psychotic reaction to prednisone steroids (for Crohn's problems) just after being diagnosed with breast cancer.

All is well now...fingers crossed.
Hope you get mother's medications sorted out. Email me if you need any further information: ***@****

Take care,
Liz.

[MLWTR]

Your mother could ask her gastroenterologist about the possibility of using total enteral nutrition. This option involves not eating or drinking anything except a special liquid formula for three to eight weeks in order to obtain remission (you can use it more than once -- that is, start at again if you go out of remission). This is an old treatment -- the first reports of its use in Crohn's go back to late 1960s, and studies still appear quite regularly in medical journals; it is not an unproven alternative therapy. It's rarely used in the United States because doctors tend to feel that it's too difficult to ask their patients to give up regular food for several weeks. It's used much more commonly in Western Europe, mainly in children with Crohn's disease. I mention it because it is particularly effective in small intestinal disease, and might be worth a try before going on to Remicaid. I've seen some case studies of elderly people doing very well with it, although you need to introduce the formulas slowly in older people during the first two or three days to avoid disturbing the balance of serum electrolytes. Anyway, I wish your mother the best of luck.

[kimbacat]

other treatments that are being used for refractory CD are cyclosporine, tacrolimus, thalidomide or the newer Revlimid (lenalidomide).  or the antibiotic combo Flagyl (metronidazole) and Cipro (ciprofloxacin)

short of a liquid diet, a low residue diet is the least offensive to the bowel.  

I understand the concern with the TNF blockers (Remicade, Humira, etc).  

take care and I wish her well.