Nonbiologic Therapy for Autoimmune Diseases

Marla Dubinsky, MD: When we talk about treatments for IBD [inflammatory bowel disease], I think we group them into “biologic” or “not.” I’ll start with the “not,” because it’s a little easier. The “not” group would include corticosteroids, which are somewhat of the mainstay of IBD treatment, particularly ulcerative colitis, given the urgency of getting those symptoms under control. Corticosteroids work quickly. About 85% of patients respond quite nicely to steroids. If you’re hospitalized, intravenous steroids are the only thing that can control the symptoms when someone’s going to the restroom every half hour or are up all night because they’re having constant spasm of their rectum giving them urgency. We must get something going quickly. Not all our treatments work as quickly as steroids. Within 24 to 48 hours, patients are feeling a lot better.

There are a lot of adverse effects, and steroids are only a short-term solution. There always needs to be an exit strategy when you start steroids. Immediately, you need to think about a companion treatment as a steroid-sparing strategy.

I’ve used steroids as inflammatory treatment. They don’t go after the biology of the disease. They just sort of Band-Aid the inflammation. Another Band-Aid of inflammation would be to use a mesalamine-based product. There are multiple mesalamine-based products out there. All of them sort of open up in the intestinal tract. Depending on whether it’s pH release or time-dependent release or colon-only release, or the way it travels to the colon, the bottom line is that they provide, again, a local, almost topical anti-inflammatory effect.

There are no mesalamine-based products approved for Crohn. However, for some strange reason, mesalamines are still used for Crohn disease, often as first-line therapy. This is unacceptable unless you have very mild, very local inflammation in a patient with Crohn—like what we call no deep ulcerations or no breaks in the mucosa. This occurs in 10% to 15% of patients. Most patients with Crohn have ulcers that penetrate beyond the mucosa. So to use a drug that works only on the mucosa is counterintuitive. That’s why there’s no mesalamine-based product approved for Crohn. Many are approved for ulcerative colitis. That makes sense because ulcerative colitis is a mucosal disease. We can all wrap our head around mesalamines in ulcerative colitis. However, for mesalamine-based products in Crohn, there’s no rule. In the vein of steroids, there are also topical steroids that, again, using pH release, release specifically in the end of the ileum.