TNF inhibitor

Often subclinical celiac, which I mentioned earlier, where a gluten-free diet alone improved bone density by 9% in a year.

Inflammatory bowel disease, so Crohn's, ulcerative colitis, where anti-TNF therapy improved bone density.

Steroid use, including high-dose inhaled steroids.

It is not just oral steroids.

So we followed the children out for a year and we saw with thyopurines there was no increase in birth defects.

We saw there was safety with anti-TNF.

And at that time, we were starting to continue TNFs throughout... you know, not just pregnancy, but throughout the patient's course, when before it was three doses, and then you give it when you need it, and we now know that that's not what you would do.

But people would still stop because they didn't know.

As far as moderate to severe disease, we want to use corticosteroids as a short-term induction agent and immunomodulators like azathioprine or 6-MP.

We're also using more of the new biologic medications like anti-TNF or integrin inhibitors.

Surgery, unlike Crohn's disease, surgery is a cure or can be a cure.

A total proctocolectomy can be curative for ulcerative colitis.

And that's where the other lines of treatment come into play.

And usually it's a conversation about of antimetabolites and then biologics, mostly TNF inhibitors, such as adalimumab or infliximab are the ones that are most commonly used.

And then personally, I usually resort to other medications, such as the interleukin-6 inhibitors or some of the newer medications if other lines fail.

That's where probably you want a rheumatologist to come in and help you handle some of those side effects because they can be significant, especially in those situations where you might have to use medications such as cyclophosphamide and chlorambucil, which thankfully for me has been rare, but I have been in some of those situations.

And listeners, there may be a reason why Dr. Coelho is asking me this question.

But I guess from my perspective, advanced therapies will include anti-TNF, newer what you'd call biologic agents and the growing range of small molecules that target specific inflammatory pathways like the JAK inhibitors, for example.

What about you, Tracey? Well, I think the answer depends

entirely on when in history you're asking the question.

The rest will need advanced therapy for the rest of their life.

And as it's now shown that early advanced therapy will affect outcomes, and we do want to avoid complications such as structuring and penetrating disease, the best strategy is to start upfront biologics.

And now the question is, what kind of biologic? Whether it should be the same anti-TNF that we use for the last 20 years, because we now have neutrals and even now one drug that is approved for children, which is not an anti-TNF.

And in the future, there will be more or keep the same strategy of anti-TNF first.

So it could be something.

Actually, you know, the person who have developed anti-TNF alpha who, who have done away with rheumatoid surgery, I mean-

Mm

... that they would be, for me, they would be candidates.

The true heavy artillery in perianal Crohn's is biological medical therapy.

We are relying on anti-TNF agents, specifically infliximab and adalimumab.

The randomized controlled trials are clear.

Induction therapy with infliximab provides initial fistula healing or significant improvement in 38% to 55% of patients, with durable long-term healing maintained in about 39%.

So I'm worried that it's going to get worse.

And so the best thing for this, the best treatment for this patient is getting them on an anti-TNF.

And so the quicker we can do that within our means and with insurance and coverage, then it'll be the best for them so that they are doing as well as they can to be taking care of themselves and someone else.

And also to interject before I forget, it sounds like she's iron deficient and quite anemic.