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Veteran Member

Date Joined May 2007
Total Posts : 1488
   Posted 2/29/2008 10:01 AM (GMT -6)   
I would have answered your question about the top down therapy in the other post but it kinda spun off into the healthcare issue!
Okay, in  my particular case I believe I became pred dependent only because my liver can't handle the Imuran at full dosage.  This is also why I believe I have to take the Humira every week instead of bi-weekly.  Having said that and accompanying the fact that my CD was so severe when diagnosed is to be taken into consideration.  My entire pelvic floor was full of pus when they opened me up. The surgeon literally had to go in up to both of her wrists before she could even view and assess the damage. Borderline abdominal rot I like to call it.
There was a 6 month time frame between diagnoses and surgery for me.  Originally, the GI did start at the bottom of the tier of drug therapy but I was too far gone to respond in a reasonable amount of time.  None of the drugs at the bottom of the tier actually had time to get into my system fast enough to advert the freefall that I was on.  Therefore, in my reasoning, the top down approach was our ONLY course of action and it worked wonders for me.  I currently have one more week of pred @ 2.5mg before I can ditch the stuff (for now).  I can safely say I believe remission has been on my horizon for over a month now...shhhhh...don't repeat that too loudly! I wouldn't want to jinx it! 
So referring back to the "small study"....I think it needs more funding at least for those of us that are moderate to severe.  I can't help but wonder if cases such as randynoguts would have received even more sucessful therapy had we had this approach to therapy "back in the day" as the kids call it.  I do still respect the fact that all these biologics are new and we truly don't know the longterm effects but at least it looks promising for me at this time.
Dx'd Jan'06, 1st Resection 7/06, Predinsone, Humira, Imuran, B12 injections, Nexium. Secondary conditions: Psorasis, Acne, Fatigue, Joint Pain, Lactose Intolerant, gallstones, fibroid cysts, peri-menopausal.

Veteran Member

Date Joined Mar 2006
Total Posts : 1169
   Posted 2/29/2008 10:14 AM (GMT -6)   
Putting aside the debate over government vs. private health care, this issue (step-up vs. top-down) therapy for Crohns is the emerging big debate among GIs. The primary proponent of top-down (starting with drugs like 6mp or remicade) is Dr. Steven Hanauer of the University of Chicago. A google search with his name and top-down will yield links to a number or medical journal papers on this. Others say it's too early to decide if that is right . . . and express concerns that if you shoot your biggest gun right off the bat and it loses effectiveness (as remicade seems to with many patients) where do you go from there? Aside from cancer, the generally accepted medical practice with most diseases is the step-up model; they usually don't treat bronchitis with the most potent antibiotics unless and until the lesser ones have failed. They try physical therapy before fusing spines, that sort of thing. My biggest concern is with the still unproven benefits of top-down . . . will it really reduce major complications and the need for surgery in the out years, when those out years may be a decade or more away? Bottom line is we shall see . . . but it seems to me that absent real evidence for the need for rapid big-gun interventiion (as in your case) a broad top-down approach is not yet justified by the studies.
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