For Bowel Diseases, A New Drug Approach
By LAWRENCE K. ALTMAN
Published: July 19, 1988
SEVERAL new compounds promise to be the first advances in 40 years in the drug treatment of inflammatory bowel disease, the mysterious, sometimes deadly disorders that afflict about 900,000 Americans.
The new drugs are appearing at a time of advances with other measures, including new operations and diets, in controlling ulcerative colitis and Crohn's disease. The two conditions are together known as inflammatory bowel disease.
While inflammatory bowel disease remains a serious ailment with dangerous complications, therapeutic innovations have spared some patients operations, made it possible for others who need surgery to lead more normal lives and made it easier for many to cope with symptoms.
''There's a general climate of optimism with fewer people dying prematurely and many more leading productive lives,'' said Dr. Theodore M. Bayless, an expert in inflammatory bowel disease at Johns Hopkins Hospital in Baltimore. ''But you cannot minimize the impact of this chronic illness because it hits people at a critical time, often in their 20's, and puts a big burden on them.''
None of the new drugs is a cure. But they may reduce the frequency of adverse reactions from existing drugs and reduce the number of attacks and the severity of complications. Some of the new drugs are still experimental and others, already marketed for treating other diseases, are being tested for use in treating inflammatory bowel disease.
Ulcerative colitis and Crohn's disease inflame the bowel to cause repeated and potentially fatal attacks of diarrhea, constipation, abdominal pain, loss of appetite and weight and other symptoms. Each disease can affect other areas of the body directly or indirectly to produce such problems as arthritis, liver damage, skin lesions, eye damage and painful cankerlike sores in the mouth.
Inflammatory bowel disease can produce bleeding and tears in the bowel that can lead to peritonitis and can increase the risk of colon cancer. Many other complications often require extensive surgery and one of them, toxic megacolon, a condition in which the walls of the bowel are stretched to the point of tearing, is potentially fatal.
But the two inflammatory bowel diseases differ in important ways. Ulcerative colitis affects only the top layer of cells lining the colon, or the last section of the large intestine. Crohn's disease - named for one of the three doctors from Mount Sinai Hospital who described it in 1932 -damages the entire wall of a section of intestine. While Crohn's disease usually strikes the small intestines, it can occur anywhere from the mouth to anus. Crohn's disease is also known as ileitis and regional enteritis.
The cause of inflammatory bowel disease is unknown. Many experts believe the incidence of Crohn's disease has risen in recent years, although they do not know why. The incidence of ulcerative colitis has remained stable. Gains Against Diseases
In addition to the promising new drugs, there are other recent gains against the diseases:
* When colons must be removed, operations that fashion internal reservoirs or pouches in the remainder of the bowel now allow people to defecate normally instead of discharging wastes into bags through an aritificial opening in their abdomen. But because the surgeons must perform dozens of operations to master the techniques to prevent serious infections and other major complications, the operations are now done in only about a dozen medical centers.
* Simpler operations make slits in the bowel wall to widen the passage when scars from the inflammation block movement through the bowel, instead of removing large segments of the intestine.
* Fully nutritious liquid diets have been developed that cause little or no work for the bowel, thereby allowing an inflamed portion to heal faster.
* Groups like the National Foundation for Ileitis and Colitis now offer patients information and support. Many doctors say it is easier for them to take care of patients who know more about their illness.
''All these things help tremendously in improving the care and the outlook for the inflammatory bowel disease patient, and provide everyone with a lot more leeway in terms of what they can do,'' said Dr. Daniel H. Present, an expert on inflammatory bowel disease at Mount Sinai Medical Center in New York. Difficulty of Diagnosis
Ulcerative colitis and Crohn's disease can mimic each other as well as appendicitis and other diseases. Because there is no single clinical feature or laboratory test to diagnose either condition, the diagnosis often is a matter of ruling out other diseases. Thus, making such a diagnosis can tax the skills of the best physician.
Treatment varies with the type and severity of inflammatory bowel disease. The principal drugs used to treat inflammatory bowel disease in recent decades are steroids and sulfasalazine (sold under the brand name Azulfidine by Pharmacia Inc. of Piscataway, N.J.).
Each can cause serious side effects. Sulfasalazine, which is related to both aspirin and the sulfa drugs, is only marginally effective when given as the sole drug in patients with active colitis. Once such an attack has been controlled, patients take it to reduce the chances of a further one.