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Crohn's Disease Forum » Ask the Experts » How to differentiate between mild and severe Crohn's Disease


05-29-2013, 11:24 AM   #1
David
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How to differentiate between mild and severe Crohn's Disease

Rygon recently asked,
How do you distinguish between mild to severe Crohn's disease?
Doctor Emmanuelle D. Williams, M.D. of the Penn State Hershey Inflammatory Bowel Disease Center took time out of her busy schedule to answer this question. A little about Dr. Williams:

Emmanuelle Williams, MD is the Assistant Director for Clinical Medicine and Education, Hershey/Penn State IBD Center.

In regards to the question, Dr. Williams stated:

Crohn’s disease presents with so many patterns, locations, complications and can also coexist with other diagnoses such as irritable bowel symptoms, that classifying disease of one patient and then comparing that patient to others is not always possible. As physicians, we try to establish severity on objective clinical findings, and then asses the global impact on the patient’s quality of life. While there are several indices of disease activity that have been used for the purposes of research studies, these are not often used routinely in clinical practice. In fact no “gold standard” indicator of clinical disease has been established in guidelines.

The majority of clinical trials have used the Crohn’s Disease Activity Index (CDAI) to assess therapeutic outcomes. The CDAI consists of eight factors (clinical symptoms during the prior week: number of liquid stools, abdominal pain, general well being and objective findings: presence of complications, abdominal mass, blood counts and need for Lomotil or opiates for diarrhea) which are weighted. Calculators are available online. Another index, The Harvey-Bradshaw index consists only of clinical parameters: general well being, abdominal pain, number of liquid stools, abdominal mass, and complications. These indexes are rarely used in clinical practice other than for classifying patients for research purposes. Studies have shown that indexes are cumbersome to use in practice and require patients to remember several days worth of symptoms, are limited due to use of subjective variables and have high interobserver variability: the results can vary widely depending on the person filling the questionnaires.

Working definitions, used more for the purposes of research per the most recent Crohn’s Disease Practice Guidelines are as follows:

-Symptomatic remission CDAI <150 : asymptomatic and have no active disease by objective evaluation. These patients are those who have responded to medical therapy or surgical therapy without any signs of active disease. The goal is for these patients to also have no microscopic findings of active disease on endoscopic biopsies. Steroid dependent patients are NOT considered to be in remission.

-Mild to Moderate Disease CDAI 150-220: able to tolerate oral nutrition without weight loss or dehydration, and do not have signs of severe abdominal pain, painful mass, obstruction or systemic findings. They have continued findings of active disease endoscopically, by labs or imaging.

-Moderate to Severe Disease CDAI 220-450: patients who have failed to respond to treatment - or have prominent symptoms including fever, weight loss, constant abdominal pain, significant anemia, more pronounced endoscopic and imaging findings.
-Severe/Fulminant Disease CDAI >450: patients with persistent symptoms despite treatment and corticosteroids, or patients with high fevers, persistent vomiting, intestinal obstruction, or severe disease complications such as abscess.

BOTTOM LINE
Severity is distinguished clearly more for research purposes than practical clinical use. As physicians our goal is to find treatments appropriate to each patient in hopes of improving their quality of life and decreasing the long term risks associated with their disease – no matter where on the spectrum of severity a patient may fall.
Thank you to Dr. Williams for her time and expertise!
05-29-2013, 07:20 PM   #2
Jennifer
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So saying mild, moderate or severe really just has to do with the treatment plan for the patient but doesn't mean that they couldn't go from mild to severe or severe to moderate etc. as its all the same disease.

I found this statement interesting, "Steroid dependent patients are NOT considered to be in remission." I always figured as much but its nice to see it mentioned by a medical professional.
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05-29-2013, 07:32 PM   #3
Johnnysmom
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When my son was first diagnosed I thought mild, moderate, severe meant something about how his disease would respond to medication and what the course of his disease would look like over his lifetime. Now I know it really just indicates how the disease is behaving at the moment.

Are there any indicators for future course of the disease?

Age at diagnosis? Constipation as opposed to Diarrhea? Types of meds that are effective?
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06-03-2013, 06:44 AM   #4
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Steroid dependent patients are NOT considered to be in remission.
Interesting statement. Does this also apply to patients on immunosupressant medication? Does it apply to the UK as well as the US?
06-03-2013, 07:03 AM   #5
DustyKat
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Hi CronoMush,

By immunosuppressant are you referring to the drugs in the class of those like Imuran and 6MP?

If so these are drugs used for the maintenance of remission so the statement is not applicable.

The science that underlies treatment protocol success and failure shouldn't vary by huge degrees from continent to continent and country to country. There will always be local differences due to the differing opinions of health professionals and the varying health systems.

A steroid dependent patient is a steroid dependent patient no matter where one resides and no, it is not remission. Steroids are not mean't to be a long term solution. It is there as a quick hard fix and then for other drugs, like Imuram/6MP, to take over when Prednisone is weaned.

Dusty.
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06-03-2013, 08:11 AM   #6
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Yes, I was referring to Imuram, although I know it as Azathioprine. I was interested due to a life insurance application and specifically a question about whether my condition is in remission. The Azathioprine does control it pretty well, but I did have a flare up last year and was on prednizolone for two weeks.

I have already been refused on the grounds of Crohn's disease and have waitied a year to apply again.

I'm also wondering whether it is usual for Crohn's sufferers to be refused life insurance on the basis of their disease?
08-10-2015, 12:56 AM   #7
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Yes, I was referring to Imuram, although I know it as Azathioprine. I was interested due to a life insurance application and specifically a question about whether my condition is in remission. The Azathioprine does control it pretty well, but I did have a flare up last year and was on prednizolone for two weeks.

I have already been refused on the grounds of Crohn's disease and have waitied a year to apply again.

I'm also wondering whether it is usual for Crohn's sufferers to be refused life insurance on the basis of their disease?
Not life insurance, but I've seen standard health insurance packages refuse 'severe crohn's'. Basic health insurance is compulsary where I live.
08-10-2015, 08:07 PM   #8
teeny5
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Interesting, I always considered mine to be mild to moderate. However, from what is stated above I was at moderate to severe for a long time. I guess I just figured that since I didn't need surgery or the stronger meds it was mild. But I was for sure not able to keep weight on, anemic, in constant pain, had a fever, among other issues.

I find it interesting that steroid dependence excludes one from remission as well. I know it doesn't apply to other maintenance drugs, but makes me think about what remission really is. If you still rely on any medication is it truly remission??? I missed a few doses once and started going downhill faster than I could have ever anticipated. Now I believe I will never be able to come off the meds and stay in remission.
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09-22-2015, 03:46 PM   #9
buttER
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In a colonoscopy, what is mild or moderate or severe colitis? Is it based on the number of lesions, or the total area affected, or something else? Does anyone know? I might put this on the general thread.
03-25-2016, 03:10 PM   #10
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" Steroid dependent patients are NOT considered to be in remission."

Does this include steroid dependent patients that are undergoing therapy for something like Addison's Disease as well as CD?
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