Crohn's Disease (cont.)
Methotrexate (Rheumatrex, Trexall)
Methotrexate (Rheumatrex,
Trexall) is both an immuno-modulator and
antiinflammatory medication.
Methotrexate has been used for many years in the treatment of severe rheumatoid
arthritis and psoriasis. It has been helpful in treating patients with moderate
to severe Crohn's disease who are either not responding to azathioprine and 6-
MP or are intolerant of them. Methotrexate also may be effective in patients
with moderate to severe ulcerative colitis who are not responding to
corticosteroids, azathioprine, or 6-MP. It can be given orally or by weekly
injections under the skin or into the muscles, but it is more reliably absorbed
with the injections.
One major complication of methotrexate is the development of liver cirrhosis
when the medication is given over a prolonged period of time (years). The risk
of liver damage is higher in patients who also
abuse alcohol or are
severely
obese. Although it has been recommended that a liver biopsy should be obtained
in patients who have received a cumulative (total) methotrexate dose of 1.5
grams or higher, the need for such biopsies is controversial.
Other side effects of methotrexate include low white blood cell counts and
inflammation of the lungs.
Methotrexate should not be used in pregnant women because of toxic effects on
the fetus.
Surgery in Crohn's disease
There is no surgical cure for Crohn's disease. Even when all of the diseased
parts of the intestines are removed, inflammation frequently recurs in
previously healthy intestines months to years after the surgery. Therefore,
surgery in Crohn's disease is used primarily for:
- Removal of a diseased segment of the small intestine
that is causing obstruction.
- Drainage of pus from abdominal and peri-rectal
abscesses.
- Treatment of severe anal fistulae that do not respond
to drugs.
- Resection of internal fistulae (such as a fistula between the colon and
bladder) that are causing infections.
Usually, after the diseased portions of the intestines are removed
surgically, patients can be free of disease and symptoms for some time, often
years. Surgery, when successfully performed, can lead to a marked improvement in
a patient's quality of life. In many patients, however, Crohn's disease
eventually returns, affecting previously healthy intestines. The recurrent
disease usually is located at or near the previous site of surgery. In fact, 50%
of patients can expect to have a recurrence of symptoms within four years of
surgery. Drugs such as Pentasa or 6-MP have been useful in some patients to
reduce the chances of relapse of Crohn's disease after surgery.
General measures
General measures which may help control Crohn's disease include dietary
changes and supplementation. Since fiber is poorly digestible, it can worsen the
symptoms of intestinal obstruction. Hence, a low fiber diet may be recommended,
especially in those patients with small intestinal disease. A liquid diet may be
of benefit when symptoms are more severe. Intravenous nutrition or TPN (total
peripheral nutrition) may be utilized when it is felt that the intestine needs
to "rest." Supplementation of calcium,
folate and
vitamin B12 is helpful
when malabsorption of these nutrients is apparent. The use of anti-diarrheal
agents [diphenoxylate and atropine (Lomotil),
loperamide (Imodium)] and anti-spasmotics also can help relieve symptoms of
cramps and diarrhea.
Next: Conclusions »
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