More Surgery Complications in the Biologics Era?

Absolutely. I agree.

But that's not what I was trying to dispute, not at all.

beave said...
Huh? What does pediatric or not have to do with disease severity?

iPoop said...
Ditto. I think there's a strong case for biologics and pediatric use.

The question was whether to administer biologics to all children, severe disease or not. If going the way of biologics is the parents' decision then at least make sure it is with informed consent. After all the black box warning associated with biologics applies mostly to adolescents and young adults.

And as the independent, peer-reviewed journal Gastroenterology & Heptology advises:
https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3264940/
Biologic agents and immunosuppressants are appropriate if patients have moderate-to-severe disease and have failed other standard therapies.

And the National Institute of Health's PubMed website has questions about biologics not only making one more susceptible to infections, but may increase the risk of cancer. Let the parents decide after, informed consent, if they want to start their children on that path or wait to see if milder meds can bring on remission.

https://www.ncbi.nlm.nih.gov/pubmed/23470503
There is evidence that use of thiopurines and anti-tumor necrosis factor (TNF) agents is associated with an increased risk of lymphoma, particularly non-Hodgkin's lymphoma in patients with IBD.

Hepatosplenic T-cell lymphoma, although rare, also occurs with increased frequency in patients treated with thiopurines and anti-TNF medications, and young male patients with Crohn's disease appear to be at greatest risk.
Furthermore, thiopurines and anti-TNF agents are associated with elevated rates of nonmelanoma skin cancer in non-IBD and IBD patients, and anti-TNF agents may also increase the risk of melanoma.

Rates of abnormal cervical cytology may be elevated by the use of immunosuppressive agents in female patients with IBD.

I think you are assuming things that were never said. Nobody is saying absolutely biologics for all children with UC, no matter what the doctor or parents think. We're talking clinical recommendation for moderate to severe cases is to go on biologics. If a parent believes absolutely under no situation can my child ever touch biologics, then of course that is the treatment course that will be taken (and nobody has said anything to the contrary within this thread). If a doctor believes a child is a very mild case and mesalamine-only treatment is the best course of action, then of course he/she will go down that route for him/her. All good doctors explain the risks versus benefits, listen to patient and parent concerns and work with them. And all good doctors base treatment courses based on patient symptoms and assess what is the appropriate and best treatment course to take with each patient, as nobody is cookie-cutter the same lol.

Introducing biologics earlier in pediatric cases makes a lot of sense an recommending that seems like a good thing. I think bottom-up approach does not make much sense for moderate to severe pediatric cases. Top up does!

But I do not think scaring folks away from taking biologics is a good thing. Yes there is a risk of a lymphoma, and that risk is qualified as 4 in 10,000 or 0.04%. I wish that never happened to nobody, however, we are talking very small, remote odds that aren't the kind of thing to lose any sleep over. As the benefit far outweighs the risk. And, again, the lymphoma risk applies predominantly to immunomodulators (as everyone in the initial inflixmab/remicade study who got a lymphoma was also concurrently on thiopurines/immunomodulators like azathioprine/imuran/6mp).

So, if I was a parent of an adolescent male child, then I would start him/her on only the biologics with no immunomodulator, without hesitation if he presented a moderate to severe case. You might not, we're all individuals and do as we choose. All purely hypothetical as neither of us have to make that decision today

Post Edited (iPoop) : 1/30/2019 7:37:14 AM (GMT-7)

I dont think anyone should be started on biologics right after diagnosis. I did not have a mild case of UC! I was severely ill and I was started on 6 Asacol a day! I improved drastically quickly. I soon had to go up to 8 and then 12 a day and add in Rowasa but I never even touched steroids until 6 years into my diagnosis. So it is bologna that mesalamines cant treat severe disease.

Before biologics, people who went for surgery included those who would have responded to biologics and those who would not. After the introduction of biologics, only those not responding to biologics (or those without access to biologics) would go for surgery, possibly after spending months or years trying different drugs during which time their disease may have progressed to something more serious. Hence the profile of patients going in to surgery has changed, perhaps to one that is more sick on average than in the pre biologics era. More sick patients at the time of surgery could lead to a higher percentage of complications during surgery. Says nothing about the safety of biologics or otherwise. Also the article i read said the research was only in US hospitals and did not account for age adjustment (people these days are on average a bit older when they go for surgery --> naturally higher morbidity) or socio-economic factors - i.e. that a greater proportion of those going to surgery may not have had access to expensive drugs (biologics) or other resources required to manage the disease effectively and so would arrive at hospital in a worse state. In all i saw nothing in this article to directly indicate that taking a biologic is more dangerous for going in to surgery. Correlation is not causality. I would be interested in seeing a more global study. And for what it's worth, given my disease course i wish i had taken biologics from day one as i probably would have had a better quality of life during these last 4 years and not had to endure the damage of prednisone (severe osteoporosis) or 9 miserable months trying to get imuran to work. Also my sister has crohns and she said they are shifting towards starting people on biologics from the get-go because in their case it really does reduce the need for surgical intervention.

In Europe biologics cost on the order of 1000 per infusion (for the drug, excluding hospital costs). If you have 6-7 infusions per year then that is indeed expensive, but not thousands per month. The doctors who prescribe the drugs are not the ones who make money from it (at least in europe). In fact when i have been for infusions the hospitals are over-crowded and the nurses are stretched, it would be much more cost effective for the hospital to put everyone on tablets, if they could.
Prednisone is MUCH more dangerous than biologics but still gets handed out like toffee in many cases precisely because of the cost barrier from biologics. I do not see them being used as a cash cow.

Poopy I didn't want to go on Remi or Humira bc of side effects. Lowering your immune system isn't good so I chose surgery. I said to myself let's stop here NOW. No more Maybe this will work'Maybe that will work. I chose surgery. Surgery didn't chose me. I'm grateful I had the brains to go ahead with it

C_Crapper said...
Do you even ever look at trials to see that 5-asa types drugs are universally not effective for moderate to severe disease?

Show us these “trials” for ulcerative colitis.