BIOLOGICAL TREATMENT FOR CROHN’S DISEASE
Medical treatment of Crohn’s disease and Ulcerative Colitis has two main goals: achieving remission (the absence of symptoms) and, once that is accomplished, maintaining remission (prevention of flare-ups). To accomplish these goals, treatment is aimed at controlling the ongoing inflammation in the intestine—the cause of IBD symptoms. Biologics are genetically engineered medications made from living organisms and their products, such as proteins. Biologics interfere with the body’s inflammatory response in IBD by targeting specific molecules – specialised proteins that play a role in increasing or decreasing inflammation. Learning how these molecules work has enabled researchers to design special treatment approaches that interrupt inflammation at various stages.
Biologic therapies offer a distinct advantage in IBD treatment. Their mechanism of action is targeted. Unlike corticosteroids, which tend to suppress the entire immune system and thereby produce major side effects, biologic agents act selectively. Therapies are targeted to particular enzymes and proteins’ that have already been proven defective, deficient, or excessive in people with IBD and in animal models of colitis.
I received Humira for my Crohn’s Disease from December 2011 to January 2013.
It is also called Adalimumab, a biological medical treatment for Crohn’s Disease and several types of arthritis. It is what is called an Anti TNF inhibitor and follows in from Infliximab. It binds to TNF alpha preventing it from activating TNF receptors. In simple terms, it stops my bowels from reacting from inflammation; turning off my cells from fighting it.
It is licensed for use in adults and children with moderate to severe active Crohn’s Disease where other drugs such as immunosuppressants and steroids have not worked or are unsuitable. It is also a possible treatment for moderate to severe Ulcerative Colitis if conventional therapy hasn’t worked or isn’t suitable.
Sounds rather amazing and complicated, and it is. But it comes with some risk: It lowers the patient’s immune system, leaving them subject to catching infections easier and fighting them becomes longer and harder than healthy people. It used for moderate to severe Crohn’s Disease sufferers. It can be used for up to a year, and after review, continued beyond 16 months.
I began my treatment of this drug back in December 2011. I had only been diagnosed with Crohn’s three months previously. I started as everyone else does: on Prednisolone and Pentasa, moving onto higher doses within a couple of weeks, being admitted and moved onto Azathioprine, and finally being admitted a week after starting Aza with a very bad reaction and horrible flare up. Humira was presented as an option before I started Azathioprine and I was granted funding for it soon after.
I started my initial loading doses in early December. I went through the pre-screening tests: Chest X Ray, blood work, medical history and removal of other medications (except Prednisolone and Adcal calcium). I used the preloaded subcutaneous pens that I injected into my thigh. I started with two pens – of 40 mgs each – in each thigh on one day. The following day, the IBD nurse got me to do the same under her supervision. Two weeks later, I was due for my third load – a single pen of just 40mgs. Two weeks after – my final hospital administered injection of 40mg – I was then released to do them at home on my own, with no supervision.
I started doing one injection bi weekly at the start of January 2012. At first it was brilliant. I felt much better right away. I was bouncy and happy and had a great appetite. This continued until the start of March. Then things began to tailor off – I was back at work doing a full-time schedule and found it hard to keep up – and my attitude and behaviour changed. I was moody and annoyed quite easily, and found myself binge eating. Then in early April it felt as if my medication just wasn’t lasting the full fourteen days. I could go about 8 or 9 days without feeling sick or unwell but after that benchmark, I was feel drained and just very agitated, wishing away the days to my injection date. I used to be so good on those days. Then the fear of the needle started.
I got sick in early April – I caught a very bad cold from someone at work and it took ages to get rid of it. I got very stressed out, knowing my injection was coming up and I could not give it to myself whilst still sick. I wasn’t enjoying doing it like I used to, I knew that in reality it kept my Crohn’s at bay and avoided bigger flare ups – giving me an almost normal lifestyle – and I’m very grateful for that. But that needle, it gave me a sinking feeling in my stomach. I had to get my injections done by someone else for a while, until I was able to regain some confidence and get back in control again.
The intense pain I was experiencing within my joint meant that I came off Humira in January 2013. With the support of my GI, I was going to try to go medication free for as long as I could. I was extremely hopefully in the beginning but it wasn’t to last. Throughout the rest of 2013 I battled numerous infections, abscesses, and increased IBD symptoms. In September, I was called in for my two endoscopy procedures to assess if was a candidate for Infliximab funding. After those 5 months, the scopes found more areas of diseased colon – noticeably more in the sigmoid, development of two stricture sites and cause for concern in the terminal ileum. Oh and a hiatus hernia at the bottom of my oesophagus. I was ordered back in for blood work to attach to my funding application my GI and IBD nurse were making the following week.
I started this treatment in December 2013.
It works in the same way as Humira does, but has not be fully humanised. Infliximab must be delivered in hospital because of this reason; to keep patients under observations for side effects or reactions. Infliximab and Humira share the same side effects – lowered immunity, increased risk of infections and common illnesses. For my Inflixmab to take place, I had to have regular check up with my GI – between 8 weeks and 3 months – and pre-Inflixmab blood work. This was to check my CRP, LFTs and WBC to insure that I am healthy enough to take the medication. I also go through pre-sepsis checks – asked about my general health, if I have seen any other medical professionals in the prior two weeks and if I’ve receive any other medications – to avoid drug interactions and for my patient chart – or could be pregnant. I need to fulfil the criteria in order to receive my medication.
Seems contradictory, to be healthy enough to make sure I can take the medication, as when I have just had it, my immunity is at its lower and I am susceptible to colds and infections. This wasn’t a big issue in the first couple of months. After a loading dose on week one, I went back two weeks later for the second, and then returned four weeks after that to start the program properly. This period is critical; each patient is assessed to see how well their body has accepted the medication and if it is worth continuing. Luckily for me, I responded very well, despite not being biologically native – meaning I have a medical history of biological treatment (Humira) and might not have responded well to the same drug again.
My infusions took place at my local hospital every 8 weeks. The week before hand I’d need to go and have my blood taken, ready for my appointment with my infusion nurse. As the amount of infusions increases, the amount of time infusing and observing decreasing. I started with a two hour infusion and a two hour observation time for my first three infusions then down to a hour for each and finally after 6 infusions, down to just one hour infusion. This made it much easier to just spend a couple of hours there, instead of almost a whole day like I was in the beginning.
Reactions to biological treatment can happen at any point. My nurse makes a point of the “ten rule” – “10 minutes, 10 hours, 10 days” – to which a patient is likely to react. Whether or not this medication is continued is up to time, unfortunately. After just over a year on Infliximab – In early 2015 – I started to become symptomatic again. They decided to do specialist blood work – testing for antibodies and drug levels to see how well I was retaining the drug. It was soon found that I had extremely high antibodies and very low drug levels. This meant that my body was creating antibodies to the drug and was hardly retaining it in an eight weekly cycle. First point of call was to add a secondary drug into my treatment plan to see if helped – Methotrexate. I had a loading dose of 10mg then moved up to 15mg and finally 20mg over a month. I had to take thrice-weekly folic acid to counteract the drugs side effects. It was hoped that this low-dose chemotherapy drug would help aid my drug levels and I would start to get more from the Infliximab. By the end of three months I had only made a slight improvement, so they increased my Infliximab to every six weeks. This was not good. I could only have three of these before they took the specialist blood work again and made a decision if Infliximab was working or failing. I knew I was coming close to having no treatment plans left to try to needed something to come along and help me out; at least until I was at a point where surgery was 100% necessary.