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Small study supports top-down approach to treatment

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Posted 2/28/2008 1:15 AM (GMT 0)
Anti-TNFs used early in treating Crohn's showed remission rates superior to using steroids in a small study in Europe. For those interested: http://www.reuters.com/article/rbssHealthcareNews/idUSL21625820080222

Forgive me if someone has posted this previously. I admit to being MIA recently. smurf

Posted 2/28/2008 3:52 AM (GMT 0)
I can attest to the success of this type of therapy. This is the very approach my GI took with my moderate to severe crohns. While I was at the point of surgery by the time I was diagnosed, she didn't hesitate to be aggressive with my therapy. Once I got through the resection and meds adjustments, I am proud to say I'm almost entirely off prednisone. (1 and 1/2 weeks to go)! If all continues to go well I may even be able to back off the Humira to once every other week which is my goal. I would recommend any newbies to think seriously about this type of therapy BEFORE they start throwing you the predinisone.
Posted 2/28/2008 7:32 AM (GMT 0)
*sigh*

Unfortunately, I don't think the govt would ever endorse top-down therapy in countries like mine that have fully subsidised medicine.

Thanks for this, Ides.

Ivy.
Posted 2/28/2008 10:52 AM (GMT 0)
Ides,
Thanks very inresting article.

teddybear
Posted 2/28/2008 12:34 PM (GMT 0)
That's an interesting post Ivy -- and correct. One of the greatest drawbacks of socialized medicine (or single payer systems or whatever you call them) is that they inevitably ration health care and take most decision making powers out of the hands ofthe doctors and patients and place them in a bureacracy where clerks somewhere far away decide what is best for you, based on charts and tables and other things that may have nothing to do with your actual condition. There's a reason people in England have to wait nine months for elective gall bladder surgery while those in the US can go get it done next Tuesday.

Posted 2/28/2008 1:11 PM (GMT 0)
My GI is a big proponent of top-down and this article is interesting. I must say that I have seen many articles saying opposite results so I still an uncertain what is the "best" option. I think Broom is a great example of one way being right at the right time. Broom...what would your opinion be if you were not Pred dependent? Would you still have gone the top-down route. I am truly curious....I have opposed top-down because I am not pred dependent, have not had it much in the past and am 18 years status post surgery---do I really need that route.

My point (after rambling) is that top-down needs to be researched based on the patients starting point.

Mike...I agree...won't say more because it causes debates.
Posted 2/28/2008 7:30 PM (GMT 0)
Except the 37,000,000 people in the US who are uninsured. They might have their gall-bladder out in one day, but they might have to mortgage their house and put the money on the table before the surgeon cuts. Or, they might be so afraid of incurring the costs of a visit to the doc that they put off having their symptoms checked until the gall bladder ruptures.

the Publicly funded health system I'm familiar with uses something called best standards to evaluate care. As the medical protocol changes so to will the standards of practice. Ivy it really has more to do with accepted standards. Until recently, the accepted standard for treating crohn's has been to move up through the tier of drug therapies because of the known side-effects of the more powerful drugs. As evidence-based research makes the case for altering that approach, you will see physicians in publicly funded health systems change their standards of practice.

Don't forget the profit motive that motivates a lot of the health care spending in the US. I think a lot of the tests, procedures and drugs i see people being subjected to (and their frequency) as being at least partially about lining the pockets of hospitals and physicians. They see an insured patient and dollar signs start a-ringing. Be interesting to look at a comparison of outcomes for given diseases between the US and a place like Canada, Britain or France. Do you really think that morbidity and mortality statistics would favour the United States?
Posted 2/28/2008 7:36 PM (GMT 0)
I don't think that doctors get paid any more or less for the drugs they prescribe, at least I still believe that is true in the US.....some doctors do have jobs as consultants for drug co's, but that's isn't really a motivation to sell that company's drug over another is it?
Posted 2/28/2008 8:38 PM (GMT 0)
Doctors get paid piece meal. Every procedure etc. is money in their pocket. Same for health care facilities. And when a third-party insurer is footing the bill, there is an incentive to over-book procedures. Doctors might not get a percentage of the cost of the prescription, but they get "paid" through junkets and dinners, and special gifts. drug companies fund cruises and conventions and a whole host of "freebies". And that influences prescribing practice.

Add to that the abuse of advertising through which drug companies do end runs around physicians to get at health consumers directly, and there are an enormous amount of medications being inappropriately prescribed. A lot of the stuff that passes as Continuing medical education today is just a way to disguise perks given to docs by drug companies. And that is also happening in places with socialized medicine as well, it's just that there seem to be more checks and balances in a socialized system because it is not for profit.
Posted 2/28/2008 8:43 PM (GMT 0)
Mike re-reading your post I am stunned by your summation of not-for-profit health care. Your description is exactly how I have been led to believe that health care is being rationed in the states through HMOs. It has not been my experience with not-for-profit systems. A degree of restraints on the system, yes, but decisions being made by accountants and clerks instead of physicians? I don't think so.
Posted 2/28/2008 8:50 PM (GMT 0)

I would refer you to several authoritative studies by the Cato Institute re the many many problems associated with gonvernment-run health care. (Simply go to their website) The evidence is very clear re long waiting lists, lack of availability of procedures and technologies, etc. in Canada, the UK and other European countries (and much higher tax rates to pay for all of that.) Those systems are essentially a gigantic HMO with government authority behind it. The for-profit health care system has drawbacks to be sure . . . but it also has incentives to develop new drugs and technologies which government run systems do not. As for doctors making prescribing decisions based on drug company junkets, really . . . doctors want patients to get better, if only because they aren't constantly coming back for re-visits. They prescribe what works best, not the drug written on the free ballpoint pen they got from a drug rep.

Bottom line, if you love the POst Office and think it is wonderfully efficient, you'll love government health care . . . or drop by the VA hospital and see how government health care operates in microcosm.

Posted 2/28/2008 9:44 PM (GMT 0)
Bellenstein, i agree with you on most of what you are saying, especially the ridiculousness of advertising Meds on television! what a waste of money and a horrible idea!

but, tend to agree a bit more with Mike, doctor's aren't as into going to "contiuing education" stuff as you would think. I bet many of them are busy and tired of traveling to seminars that they would only see as a sales pitch...

however, Mike, you are wrong about the post office, while they may seem slow, they are by far one of the most efficient means of getting a original copy of a letter from one place to another.. locally, in Los Angeles, mail only takes one day between most cities in Southern California and only costs 44 cents! that is better than any privately owned company could do! the USPS is handling billions of pieces of mail to millions of addresses, and rarely gets it wrong...

on a final note, HMO's are needed to provide health care to many people for a low price, yes, the rates for individual and group policeis are high, but they are higher for PPO's for a reason.....that system just isn't feasible for the all of those who need heath care.

yes, I do work in the insurance industry, though not health insurance. as a result, I understand that insurance works because lots of people are putting into a system that not everyone gets to take out of, without insurance though, business in a modern economy would be impossible, it doens't mean that when bad things happen, you don't lose something, but at least you won't lose everything.

It's the same way with healthcare, in a perfect world, we would all get every test and drug and surgery we needed for the best possible health, but we don't live in a perfect world, so instead, we have HMOs to give us the next best thing.....

yes, the HMO's are in the business of making a profit.....so are farmers, and so are clothing manufacturer's, and so are most churches, and so are universities.....
Posted 2/28/2008 11:50 PM (GMT 0)
Oh, sorry. My little post has sparked a debate. Sorry, all.

Just for the record, I love our system of socialised medicine. I'm not wealthy and I've never been well enough to work. I can't imagine what would have happened to me had I been born in the US rather than Aus. It's just that, sometimes, the system has its drawbacks - such as the great difficulties we experience in getting anti-TNF meds. With 20,000 Crohn's patients in this country, I think it would take some overwhelmingly compelling evidence to convince the govt to fork out $20K / year to provide us all with Rem or Humira instead of the relatively cheap Pred and Imuran.

Still, they do it for cancer patients, don't they? Some chemos are as expensive as our meds.

I.
Posted 2/29/2008 9:28 AM (GMT 0)
hi guys.... mike, i will take exception to 2 of your comments.. 1st, the post office. ours is the most efficient in the world and one of the least expensive for what is delivered. universal delivery, no other country has it, for one price a letter to anywhere else in the country. and the more mail delivered than the rest of the world combined....

2nd, the VA healthcare system, every healthcare system has its problems, i can say with confidence that the care i have received through the VA has been as good or better than any private care i have received.


and for the HMO detractors, all depends on the system, i have belonged to a not for profit HMO for 21 years. they have never so much as questioned a drs order for me. and have to date spent well over a million bucks on me. randy
Posted 2/29/2008 1:14 PM (GMT 0)
I tried to stay out of this now didn't I :-)

Just wanted to say....don't necessarily believe the stat of 37mil uninsured. They are counting people that you wouldn't consider.....they have included those rich folks that opt out of insurance, they include many who are in self-insured programs and have benefits as good or better than a standard insurance company & in the past they found they counted people who opted out of their plan simply because they had coverage elsewhere.
Posted 2/29/2008 1:51 PM (GMT 0)
And don't forget the young to early middle age, healthy workers, who elect to NOT purchase health insurance - yet - because they ARE healthy. I'v worked w/some of those.

Plus I have to support Randy's statement as a reminder to you all: the USPS is THE most efficient postal service in the world, one of the least expensive, delivers more mail than any other country and provides mail service to EVERY resident's personal delivery address.
Posted 2/29/2008 5:10 PM (GMT 0)
There are several significant differences between HMOs and publicly funded health plans. HMOS are for profit institutions and by definition are exclusionary. They often have lifetime caps and other devices that constrain costs. Another way to restrain costs is to limit the people and conditions covered. What about pre-existing conditions? A publcly funded health system accepts all under its umbrella and there are no lifetime caps. When Canada accepts an immigrant, we don't dig into his past medical history and refuse him treatment because he had the condition before arriving in this country. Speaking of studies, what about the WHO studies on life-expectancy, etc? Where do countries llike Canada, Sweden, Denmark, Great Britain, Germany, Australia, France etc who have not for profit publicly funded health systems, stack up against the United States in those studies? If these countries offer such aggregiously sub-standard care in comparison to the States, why do they outperform the states in almost every measure of health outcome?


Clearly there are benefits and disadvantages to both systems and there is plenty of room for discussion and debate. But publicly funded medical systems are just not the terrible nightmare that some seem determined to portray.
Posted 2/29/2008 9:37 PM (GMT 0)
Regarding the top down theory: I think that the really astute gastro will take this theory into consideration when evaluating each of his/her patients.

For instance, to my way of thinking, if a patient has a mild form of disease, for instance, it is located in just one area and responds to a short regimen of pred or Entocort, then initial medication(s); then stay w/the lesser meds that are working.

If a patient has a more aggressive form w/skips to more than one area of intestine, or doesn't respond to the early meds, or responds only to pred (or Entocort), then hitting that patient w/the "big guns" may well be the way to go.
Posted 3/1/2008 2:03 AM (GMT 0)
I agree crohnie

The real challenge is going to be setting criteria for which approach to take. And the medical options now available makes it even more important for patients with chronic illnesses to take some responsibility for knowing and acknowledging what is actually going on inside them. And reporting accurately to their health providers. Sometimes that isn't easy, especially if you have the smouldering type of crohn's that, early on, is so easy to push aside. The deterioration is so gradual that it is easy to accept the increasing limitations the disease exacts -- until wham, you end up needing a resection, or you get a free perforation or abscess etc. By then you've run out of medical options.
The key is whether, for this kind of crohn's, early aggressive medical intervention can significantly delay the fibrosis that eventually leads to stricture and obstruction in these cases.

Even though my health is now compromised after so many years and so many surgeries, I feel like after my last resection I'm sort of at a new beginning. I am a different patient and my internist's response is now completely different too. I am reporting symptoms much more quickly and with an honest attempt not to minimize, and he is treating much more aggressively -- though we have both agreed that, for now, the biologics aren't warranted. We'll see how the latest increase in azathioprine goes. By the way, did you notice the recent article on imuran and pentasa. It seems to indicate that the combination of the two can produce a beneficial result.
Posted 3/1/2008 10:07 AM (GMT 0)
belleenstein, i must correct you, not ALL HMO's are for profit. the one i belong to started in WA state in the 1940's and has over 500k members. it was purchased about 10 years ago by Kaiser permanente, but the care has not changed. it is still not for profit. and to reiterate, care is not rationed at all. if your dr says you need something, you get it from home health care, to minor things.
Posted 3/1/2008 6:02 PM (GMT 0)
No, Belleenstein, I didn't see that article. Its been a combination of Imuran and Pentasa that has kept in me in symptomatic and/or total remission for the last 5 years. This past year I've cut out the Pentasa a couple of times and after a couple of months I'd get some very mild hints that that wasn't such a good idea and back on the Pentasa I would go. I've been totally faithful to the Imuran since first starting it. (Who wouldn't prefer to take 1-2 tiny pills over 16 capsules a day?). I begrudge the 16 Pentasa a day but ..... (and yes, I know I can get the double dose size and only take 8 a day, but I have trouble taking pills or capsules of that size so prefer to stay w/the 16 capsules a day size as the lesser of 2 evils *sigh*).
Posted 3/2/2008 12:42 AM (GMT 0)
This has been my experience too. My doc has been suggesting I come off pentasa since early last year, saying the imuran should make the pentasa unncecessary. Each time I've tried to come off it, I've had an increase in symptoms. At my most recent appointment, we agreed to increase my azathioprine because I'm slipping again. Once I adjusted to the increase I was going to try and get off the Pentasa again. I'm in Canada and the company doesn't sell the 250 mg tablets here. I have huge issues with my throat and when the 500 mg tabs get stuck it irritates the esophagus. I worry long term about the damage being done. But now, I'm not sure.

The article was in the recent edition of American gastroenterology.

http://www.ncbi.nlm.nih.gov/pubmed/17764493


Randy I'm sure you know how lucky you are, given your situation, to have the health coverage you enjoy. I don't think it is typical of most HMOs but I am glad to know that within the HMO model there is room for non-profits. I just can't figure out how a non-profit can be purchased? Why would a company purchase something fthat is designed not to realize a profit?

[*I just activated the URL - C2]

Post Edited By Moderator (CrohnieToo) : 3/2/2008 8:50:28 AM (GMT-7)

Posted 3/2/2008 1:06 AM (GMT 0)
Ooh, good question, Beeleenstein. Could it be a tax break?
Posted 3/2/2008 4:56 AM (GMT 0)
what they did was to purchase/combine the two systems . just that the other system had more money to invest so got control over the board of directors.. the reason was to increase economy of scale.. so they can get even lower prices on things from suppliers. if they can get 100 widgets for 100 bucks each, then they can get 200 widgets for 75 bucks together saving both money and being able to keep premiums lower and increase coverages for more things. or like buying each one 6 MRI machines, much better prices for 12 than two orders of six, see?
Posted 3/2/2008 10:09 PM (GMT 0)
If this works as a non-profit on this scale, and you don't exclude anyone, then why wouldn't it work to provide universal health care for all Americans? Wouldn't the same economics of scale apply -- oh, except I forgot, didn't your government pass a bill that doesn't allow the government to bargain with drug companies> So how does that work? If your HMO can bargain, why can't your government bargain to get the best price?
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