Aline Charabaty, MD, on Managing Mild Crohn Disease

Dr Charabaty reviews her approach to treating mild Crohn disease in adults and children.

Aline Charabaty, MD, is the assistant clinical director of the division of gastroenterology and hepatology at Johns Hopkins School of Medicine in Baltimore, Maryland, and the clinical director of the IBD Center at Johns Hopkins Sibley Memorial Hospital in Washington, DC.

TRANSCRIPT:

Dr. Aline Charabaty:
Hello everyone. I'm Dr. Aline Charabaty. I'm an Assistant Professor of Medicine at Johns Hopkins School of Medicine in the division of Gastroenterology and the Clinical Director of the IBD Center at Johns Hopkins Sibley Memorial Hospital in Washington DC. I am very excited to be here at AIBD 2022 and we just had a very interesting session focused on how to manage mild Crohn's disease. As you know, most of the time when we're talking about Crohn's disease at conferences, in term of therapeutic management, we're really focusing on moderate to severe Crohn's disease where we typically use immunosuppressive therapy such as biologic.

But how can we approach mild Crohn's disease? So first, let's define what mild Crohn's disease mean. This is when you see superficial aphthous ulcers in the colon or the ileum or both in a patient with minimal GI symptoms that are not affecting their quality of life, their diet or their health overall and their weight.

These are typically patients that are nonsmokers and there are no extraintestinal manifestation associated with these findings. And these findings are stable over time if you repeat the colonoscopy. So in other words, you can say that in mild Crohn's disease, we have absence of strictures, fistula, perianal disease, abscesses, upper GI Crohn's involvement, deep ulcers or extraintestinal manifestation. So when you have a patient with mild finding on endoscopy and mild symptoms, what do you tell them? What is the natural history of their Crohn's disease? Are they going to progress to more severe Crohn's disease that would require immunosuppressive therapy? The data there is limited, but we have some data in the peds and in the adult population and it seemed like around 15% to 20% of patients will progress to more moderate to severe disease several years down the line. So these are patients that would benefit from monitoring their symptoms, their inflammatory biomarkers, and their endoscopy finding.

So when you have a patient with mild Crohn's disease, what are our goals of care? So in this patient, the risk of immunosuppressive therapy doesn't really make sense. Our goals here are to control the symptoms while avoiding the potential risk of immunosuppressive therapy.

So what options do we have? One is smoking cessation. So if your patient is a smoker, recommend smoking cessation and encourage that and work with the primary care doctor to achieve that goal. Two is diet. So we have very good data on the role of diet in the pediatric population. We know that exclusive enteral nutrition induced remission in peds population with mild Crohn's disease. And more recently, a easier diet to follow, which is partial enteral nutrition with the Crohn's disease exclusion diet show even better result than EN in inducing remission in the pediatric population. Just as a reminder, the Crohn's disease exclusion diet exclude animal fat, red meat, milk and wheat, as well as additives and encourages fruits and vegetables.

So this is in the peds population. How about in adults? A recent study by Jim Lewis looked at the specific carbohydrate diet and the Mediterranean diet in patients with mild Crohn's disease in the adult population. And both diets were very well tolerated and both diets improved clinical symptoms, but we did not see an improvement of the CRP. So these diets can be beneficial in controlling the symptoms, knowing that they might not necessarily control the inflammation.

How about medical therapy? This is really where also we are looking at therapies that are nonimmunosuppressive or a very short course of steroids. So you can use a short course of prednisone or budesonide to induce remission followed by mesalamine or sulfasalazine. Mesalamine has been shown to be superior to placebo in patient with mild Crohn's disease and sulfasalazine has been shown to be effective in Crohn's disease affecting only the colon. So these are treatment options that you have for your patient with mild Crohn's disease.

So just to summarize, mild Crohn's means minimal superficial aphthous ulceration of the GI tract with absence of complications of Crohn's disease with minimal symptoms that are not affecting the overall health and quality of life of the patient. Our goal is to control the symptoms while avoiding the potential side effect of immunosuppression. So you can use budesonide, mesalamine, sulfasalazine. But it's very important to keep monitoring these patients and make sure they're not developing features and complications of moderate to severe Crohn's disease that will require completely different therapy. Thank you for joining us and we hope to see you at AIBD 2023.