B12 is available in nasal form. How does that compare with classically injected B12?

The uselessness of sublingual Vitamin B12?

In the past I criticized the use of sublingual vitamin B12. Now there is nasal B12 available. A recent article in Gastroenterology[1] showed that nasal B12 is effective in treatment of B12 deficiency, using a dose of1.5 mg per day.

Patients with Crohn’s disease often have involvement of the last part of the small intestine, which is known as the terminal ileum. That part of the intestine is responsible for absorption of vitamin B12. Vitamin B12 is a large molecule that will not cross any part of your body unless it is specifically brought across by a transport system. For B12 this requiresa system that involves a special protein made in the stomach, called intrinsicfactor, and the transport system in the terminal ileum which brings B12 into the body when it is bound with intrinsic factor.

What is interesting is that there is a second way to absorb B12 that does not depend on the usual route. This pathway was described years ago, but requires high dose of B12, about one mg per day. I suspect that the B12 given nasally is eventually swallowed and absorbed by the intestinal route.

Interesting that now B12 is available in these formulations. While true that one gets away without a shot, the dose is about 300 times what is given orally. I imagine that 350 to 475 mg of vitamin B12 a year adds up in cost, and it may indeed be cheaper to just get a yearly shot of 1 mg of B12. Add to that the cost of testing to see if the oral or nasal B12 is getting in the system, and I wonder about the cost.

Patients with Crohn’s are at risk for B12 deficiency. Blood counts should be done regularly. In the future, as folate is added to the diet, looking for large blood cells as a clue to B12 deficiency will no longer work, so B12 levels will need to be every few years or so to detect the developmentof B12 deficiency in patients.

Stephen Holland, M.D.
Section of Clinical Pharmacology
University of Illinois College of Medicine at Peoria

1. Slot, WB and Merkus, FW and Van Deventer, SJ and Tytgat, GN. Normalization of plasma vitamin B12 concentration by intranasal hydroxocobalamin in vitamin B12-deficient patients. Gastroenterology 1997 Aug; 113(2):430-433.

## How do doctors deal with patients who have incurable disease?

Ever wonder if your doc gets frustrated over not being able to cure incurable disease. Do you worry that you are only darkening the door of your physician, sorry to trouble them over something they cannot cure anyway? A reader asked, and I answeredHow do doctors deal with patients who have incurable disease?

I’m truly curious as to how doctors deal with the frustration ofdealing with people they can’t, despite their best efforts, cure. I’m wellaware that my doctors are doing their best and that there isn’t a cureor quick fix — I wonder if they know I know that (and of course, I dotell them). Nonetheless, sometimes I hate to even darken their doors withyet another complication or flare-up — perhaps because I am so fond ofthem and appreciative of their efforts. I sometimes think we patients –with all our kvetching — would benefit from an understanding of our physicianson this human level. It’s not a topic I’ve ever seen or heard addressed.

Oh, yes, this is a common question of Doctors. Well, I think it is. I actually haven’t canvassed my fellow physicians on this one, but I have had friends ask me.

Actually it is quite easy. Starting out in medical school, one imaginesthat you will become a docto n sae lives. Then you got on the wards, andthe livess are not that easy to save. After the shock of realizing thatone is unable to cure everything, the young physician learns to do thebest they can. I think ther ismoreto it then just the best that you can.For myself, I have also found a way of looking at the issue that workswell for me. I have decided that my role is to give advice. This has mademe much more comfortable. My ego is no longer dependent on patients takingtheir medicines. Nor does my ego anymore depend on the virulence of someonespnuemocccus. By realizing that I give advice, I am in balance with my abilityto impact the world. When a patient is not able to follow my advice, Ino longer feel frustrated, I look for ways to give better advice. Whenthings do not work as planned, I recognize that information is imperfectand I look for more information in order to give better advice. When Idecide on what initial tests to do, I do not fear not getting every testpossible. I get sufficient tests to allow me to give reasonable adviceunder the circumstances.

Say someone has a terminal disease. I find out what last things theywant to do: such as get to their sons graduation. Then I give advice onhow to best achieve those goals. Sometimes the effort will need to be greatto get a few extra days, but it will be worth it. With Crohn’s, I knowwhat the odds and consequences are of different choices, so I give adviceon how to deal with problems as they occur. As advice depends on goals,it is a natural extension to involve my patients in the decision makingprocess, not to decide what is the correct thing to do, but to help meunderstand what different consequences mean to my patients, so that theadvice I give makes sense in the patient’s contest. So my measure of successis whether the advice caused the best possible outcome given the circumstances.

So the next time you worry you are darkening your docs door, remember that you are not there for a cure, you are there for advice. By having a physician that understands your situation and goals, and by providing feedback on how the disease and treatment are being tolerated, you will be able to get advice to help you deal with the situation at hand.

Best of Luck,

Stephen Holland, M.D.
Section of Clinical Pharmacology
University of Illinois College of Medicine at Peoria

## You want to get Pregnant while on Azathioprine?

Many women with Crohn’s are on azathioprine, an immunosuppressant. What should you do if you want to get pregnant while on azathioprine?

The subject of pregnancy and inflammatory bowel disease has been writtenabout extensively. Treatments are changing, and one worries about the effecton the unborn child. One reader wrote the following:

Thanks for an informative web page. I also subscribe to the IBD list and appreciate your comments. I have looked through some old IBD posts and saw where you said taking Imuran when conceiving a child gave you the willies. I was diagnosed with Crohn’s in 1993. I am now 27 years old and my husband and I want a child. I have been taking Imuran (50 mg a day)since November 1994. My GI has reluctantly agreed to let me try to taperoff Imuran. He feels Imuran is the reason that I was finally able to taper off prednisone after 3 years. I have been on Pentasa since March 1994.My GI feels that I will have a flare up when I discontinue the Imuran andthat would be a greater risk to the baby than the risk of birth defectscaused by continuing to take Imuran. My OB says the Imuran is unsafe duringpregnancy. I also would like to breast feed and Imuran would make thatimpossible. I’ve been told by my GI and OB that Pentasa is safe during pregnancy.

The above situation is a real example of the problems that face onewho is contemplating pregnancy with Crohn’s. The physicians seem to begiving contradictory advice. Actually, each is concerned about the outcomefor the patient, and different factors come into play.

While no one advocates the use of Azathioprine in pregnancy, the reportsof the outcomes for patients on azathioprine who get pregnant seem to beno worse than the results of patients with untreated Crohn’s. That is tosay, fetal loss is common in active Crohn’s and also when on azathioprine.The incidence of birth defects is not higher when on azathioprine. My interpretationof this is that if azathioprine causes birth defects in a given pregnancy,they are so severe that the fetus will not survive. There was some controversya while back on what the effect of pregnancy on Crohn’s is. I think theliterature pretty much now shows that people respond variably, but thatif Crohn’s is active at the time of conception that things will probablynot go well.

All that said, most drugs used in treatment of IBD have been found tobe safe during pregnancy. Steroids are known to be safe, as is sulfasalazine.Mesalamine is probably safe during pregnancy. Flagyl is not to be used(though the data I recall are just scattered case reports, and the warningto not use it may not stand up in the future).

Remember that many people were successfully treated with medicationsbefore azathioprine came into common use for Crohn’s disease. While azathioprinemay be used to get a patient off steroids, the situation generally is notthat steroids were ineffective, but that steroids were needed chronicallyand side effects were a concern.

My feeling about this is that since pregnancy is self limited in duration,getting off azathioprine at worst will mean 12 to 16 months of steroids.If the Crohn’s can be controlled with other medications, then all the better.In general, I would advise patients on azathioprine to get off the azathioprineand start steroids, a form of mesalamine, or both depending on circumstances.Also, I generally advise Crohn’s patients to avoid anything with sucrosein it, since some studies in the past showed a 50% reduction in complicationsof Crohn’s when that was done.

The above notwithstanding, there is the possibility that a particularcase of Crohn’s was so bad that even the thought of recurrence is painful.I could imagine someone who had multiple fistulas, obstructions, operationsand wound failure, was starting to get cataracts, and who only got outof a cycle of repeated hospitalizations when put on azathioprine. A casesuch as that might warrant the risk of azathioprine.

I cannot tell what is the right choice, however. This will depend onhow the risks sound to you and many aspects of your views on life, death,having children, and dealing with birth defects. It is not your responsibilityto make the medical decisions, but the input to your physicians on howyou value the various outcomes will let your doctors, who have a sensefor the relative rates of occurrence of the above outcomes, give betteradvice on how to proceed.

Best of luck in your efforts!

Stephen Holland, M.D.
Section of Clinical Pharmacology
University of Illinois College of Medicine at Peoria

## Sucrose Restriction in Crohn’s Disease

There were some papers in the past that found that sucrose restriction can prevent recurrences of Crohn’s.

Can reduction of sugar intake reduce the risk of complications of Crohn,s disease?

Since the mid 1970,s it has been known that patients with Crohn,s disease consume more sugar than patients with ulcerative colitis or normal subjects.  In this discussion, it is to be understood that sugar means the disaccharide sucrose, which is also commonly known as table sugar.  Initially, two studies from Germany showed that patients with Crohn,s eat more sucrose than healthy controls (23,28).  A number of studies since then have confirmed this finding (37).

The usual teaching is that this is due to patients changing dietary habits to accomidate their inability to tolerate many foods.  However, patients with ulcerative colitis who often have similar digestive complaints do not have increased sucrose intake (11,24,34,38).  Also, patients who have Crohn,s report that when they get sick their sucrose intake actually drops rather than increases.  Other studies show that symptoms are not changed when sucrose is restricted (1) and one study suggested that sucrose worsens symptoms (1).

Studies have been done to look at whether restriction of sucrose intake is of benefit in patients with Crohn,s.  In a study of 64 patients with Crohn,s (7), 32 patients were put on a diet which minimized sucrose and white flour, and substituted whole wheat and fruits.  While the experimental and control groups were in different clinics, the treated group had 80% less days in the hospital and only 1 patient required surgery compared to 5 in the control group.  (Interestingly, this experiment was done before the first epidemiological studies reported increased sucrose intake in Crohn,s patients).

In a larger study, results were not as beneficial (35).  190 patients treated with sugar restrictin compared to 162 treated with usual diet showed that 3.7% of treated patients needed surgery compared to 8.6% of controls and hospital admission rates were 9.5% in treated patients and 13% in controls.  These numbers did not reach statistical significance.

K. W. Heaton, one author of the 64 patient study described above (7), noted that in the
larger study of 352, patients were British and were asked to consume fruits and vegetables, a decidedly unBritish activity.  Also, the control group showed a drop in sucrose consumption, which makes it possible that the control group was really a partially treated group.  Unfortunately, a subgroup analysis was not reported with controls who did not reduce their sucrose intake.

I regularly recommend that my patients reduce or eliminate sucrose in the diet.  I allow commercial bread, which does have some sugar added, but I advise that patients do not consume anything with obvious sugar in it or sprinkled on it and do not add sugar to drinks or when cooking.  (I suspect that fermentation will have consumed the sucrose in regular bread, but not sweet bread). I recommend that a safe substitute is honey, which is fructose.

Stephen Holland, M.D.
University of Illinois College of Medicine at Urbana-Champaign.

This material was abstracted from the chapter “Dietary Factors in the Etiology of Crohn’s Disease written by K. W. Heaton, in Inflammatory Bowel disease edited by Gunnar Järnerot, Raven press 1987.

Selected References:

1. Brandes, J.W. and Lorenz-Meyer, H. Zuckerfreie Diät: eine neuer Perspektive zur Behanndlung des Morbus Crohn?  Eine randomsierte, kontrollierte Studi.  Z. Gastroenterol., 19:1-12, 1981.

7. KW Heaton, JR Thornton, PM Emmett.  Treatment of Crohn,s disease with an unrefined-carbohydrate, fiber-rich diet.  Br. Med. J.  2:764-766, 1979

11. G Järnerot, I Järnmark, K Nilsson.  Consumption of refined sugar by patients with Crohn,s disease, ulcerative colitis, or irritable bowel syndrome.  Scand. J. Gastroenterol.  18:999-1002, 1983.

23. GA Martine, JW Brandes.  Increased consumption of refined carbohydrates in patients with Crohn,s disease.  Klin. Wochenschr. 54:367-371, 1976.

24. GA Martin, A Stenner, WJ Brandes.  Diet and ulcerative colitis.  Br. Med J. 2:1401, 1978.

28. B. Miller, F Fervers, R Rohbeck, G. Strohmeyer.  Zuckerkonsum bei Patiententen mit Morbus CrohnVerh. Dtsch. Ges Inn Med.  82:922-924, 1976.

34. GB Porro, E Pnaza.  Smoking, sugar, and inflammatory bowel disease.  Br. Med. J. 291:971, 1985.

37. JR Thornton, PM Emmett, KW Heaton.  Diet and Crohn,s disease: characteristics of the pre-illness diet.  Br. Med. J. 2:762-764, 1979.

38. JR Thornton, PM Emmett, KW Heaton.  Diet and ulcerative colitis.  Br. Med. J. 1:293-294, 1980.

## An Interview with senators Kassebaum and Kennedy regarding the new health insurance bill.

Job lock is but one consequence of the current insurance system for people with chronic disease, such as ulcerative colitis and Crohn’s disease. Alaw was passed by congress a few years ago. Here is an interview with senators Kennedy and Kassebaum regarding this law that was aired on PBS in the past.

A real problem for patients with inflammatory bowel disease is the lossof the ability to get health insurance when changing jobs. This results in job lock for many. It also can be a disaster for children with IBD whocannot get health insuarnce at any new job. Recently a law was passed that would require insurance companies to provide insuranceif a person was previously insured. I get a newsletter about health issues,and am reprinting here an article I have recently received. It is an interviewwith senators Kassebaum and Kennedy.

Insurance companies are really not mean. They are simply responding to the competitive pressures that our laws have created. Suppose an insurance company wanted to be nice and just decided to insure people with chronic disease. Everyone with chronic disease would insure themselves with that company. Their rates would go up, the subscribers would leave, and the insurance company would be out of business. Thus, by being nice, they end up out of business, doing no one any good. This is an example where regulation works. By preventing all insurance companies from excluding people with previous health problems the competitive playing field is levelled, and no company can gain a competitive advantage by excluding people with preexisting illness who have previously been insured. Rates stay low, people stay insured.

There is also a long term benefit. The existance of this law makes it very desireable to stay insured. If you stay insured,chronic illness will not cause job lock or uninsurability. Under the currentsystem, if you do not get insurance and get a chronic illness you are notmuch worse off than if you are not insured at all. Insurance rates areawfully high, and many do not have insurance because of the cost. Withthe binefit of guaranteed future insurability the equation changes slightly,and more healthy people will want to be isnured to have the benefit ofthe law. With more healthy people participating, the premiums costs willbe pressured downward, and premiums can go further down as more participate.Where this settles will depend on the future premium rates and disposableincome, but it will push more people to be insured. I think this effectis not fully appreciated.

On the down side, the new law will not take effect for one year.

Thanks to Steve Freedkin for keeping the List.Healthplan active. Seethe boxed text below for subscribing information.

Stephen Holland, M.D.

Here is the article:

Here is the article:

————————- original text ———————————-
EXTRA: SENATORS KASSEBAUM & KENNEDY AS INTERVIEWED ON PBS TELEVISION AFTER PASSAGE OF THEIR HEALTH REFORM BILL 96+08+02

NOTES FROM LIST.HEALTHPLAN MODERATOR:

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(c) Copyright 1996 MacNeil/Lehrer Productions and PBS

Both Houses of Congress have approved new legislation that calls for”portable” health insurance, and guarantees that a “pre-existing”condition will be paid for, even if a worker changes jobs. Tax deductionsfor nursing home payments also made it into the legislation, but mentalhealth benefits did not.

CHARLAYNE HUNTER-GAULT: The new health legislation is first of its kindin a decade and will affect millions of Americans. Known as the HealthInsurance Portability and Accountability Act, the bill requires insurersto offer policies to workers who changed jobs, insures that workers wholose their jobs cannot be denied individual coverage, guarantees that workerswith pre-existing conditions cannot be denied coverage for more than 12months, gradually increases the tax deduction from 30 to 80 percent forthe self-employed who buy insurance, and allows individuals to deduct costsof nursing home and other long-term care.

For more on the legislation and its impact, we’re joined by the bill’sauthors. Sen. Nancy Kassebaum, Republican of Kansas, is the chair of theLabor & Human Resources Committee, and Sen. Edward Kennedy, Democratof Massachusetts, is the ranking member of the Committee. Thank you bothfor joining us. Sen. Kassebaum, just what is the significance of this bill?

SEN. NANCY KASSEBAUM, Chair, Labor & Human Resources Committee:It will enable, it’s estimated 25 million Americans, to feel more secureregarding their health insurance. If you lose — if you’re losing a jobor changing a job, you worry about whether you’ll be able to maintain healthinsurance. This guarantees that if you’ve been part of a health plan, youcannot then be terminated, and particularly due to any preexisting healthcondition.

CHARLAYNE HUNTER-GAULT: All right. I want to get into some of the specif-ics in a minute, but Sen. Kennedy, let me — do you have anything to addto what Sen. Kassebaum has said in terms of the significance?

SEN. EDWARD KENNEDY, (D) Massachusetts: Just really one point, and Ithink she has said it well with regards to portability and preexistingcondition, but I think the power of this legislation is relieving familiesof a lot of anxiety. A lot of parents have a child that has some difficulty,some disability, and the family worries what is going to happen to thatchild when he or she grows up, or that worker that might be laid off andis not as well or healthy, as robust as they might have been and is goingto be out there and unemployed and really wondering whether they’re intheir senior years are going to be able to get any kind of health insurance,or someone that would like to move to a job and have a much greater opportunityfor themselves and their family, and that says, no, I can’t do it, becauseI just don’t know about that health insurance because I have my wife issick or my husband is sick. That kind of anxiety is an enormous burdenon so many millions of American families, it’s a real one. You might notbe able to put it into dollar and cents, but it’s a real one. This billaddresses that degree of preexisting condition, and it gives assurancethat people will be able to continue their health insurance, and it meansthat they’ll be able to move from job to job and still carry the healthinsurance. That’s important.

CHARLAYNE HUNTER-GAULT: All right. Let’s go through some of the specificson it then. That is the first major thing about it, that it requires insur-ers to offer policies to workers who change jobs. Explain how that willwork, Sen. Kassebaum.

SEN. NANCY KASSEBAUM: Well, it’s just that if you’ve lost a job or changeda job and you have had health insurance, you can’t just walk off the streetand say, I want this job and I want health insurance. You have had to havebeen on a health care plan. But if you moved and changed jobs and yourCOBRA benefits have run out as well, then an employer must offer a healthinsur- ance plan. And you cannot be excluded because of a prior healthcondition.

CHARLAYNE HUNTER-GAULT: Mm-hmm.

SEN. NANCY KASSEBAUM: Also, someone can start to work and if they have,umm, a heart — a health condition, ulcers, heart condition, whatever isdetermined as a preexisting condition, after a year’s time, then they haveto not be excluded again from an employers health plan that he would beoffering employees, she would be offering employees.

CHARLAYNE HUNTER-GAULT: Now, on the first one, Sen. Kennedy, one thatrequires insurers to offer policies to workers who change jobs, who bearsthe cost of that? How does that work? SEN. EDWARD KENNEDY: The employeeand, therefore, this is — we have to see within the states, as the statesare going to have important responsibilities, that some of it’s sharedwith the federal government to make sure that the premiums are not goingto go up out of sight, and one of — that was one of the real differencesbetween the House and Senate bill under Sen. Kassebaum, our bill.

It meant that all insurance policies were going to be available to peoplethat were going to be moving out or have some preexisting condition, andthe House would have tried to put them all in one policy, which would havemeant that the premiums were absolutely up through the roof, and it madeit inaccessible for people, but I — if I could just get back to one point,you know, what happens so often in, in Main Street America, as these familieshave paid into insurance companies for a long period of time, for ten,for fifteen, or for eighteen years, and suddenly they find a husband ora wife, a preexisting condition.

They may develop cancer. You know, what happens in so many instances,they are cut off, they are terminated. That policy is ended, or if a childis very, very sick, that policy is ended. That happens, every communityin America, and this addresses that issue.

C HARLAYNE HUNTER-GAULT: But explain to me this part, where it saysit guarantees that workers with preexisting conditions cannot be deniedcoverage for more than 12 months, why is that there, for more than 12 months?What exactly does that mean?

SEN. NANCY KASSEBAUM: That’s because, as I said earlier, if you havemoved to a job that is offering health coverage but you have a preexistingcondition, and you have not been covered before, that you cannot be –you cannot be denied for more than 12 months. During that time, you wouldbe urged to be a participant in the plan, but you may not have a preexistingcondition covered until the end of 12 months time. But that’s for someonewho has never been part of a health plan.

CHARLAYNE HUNTER-GAULT: Oh, I see.

SEN. NANCY KASSEBAUM: Let me just say too, umm, it’s like any otherhealth plan. I mean, this isn’t something new. We’re not dictating theterms of new health plan. It could be Blue Cross-Blue Shield, or whateveran employer is offering, so an employer may pay part of the benefits asthey do in, in many plans, or it would be employee contribution. That isto be determined. It’s just that they cannot be denied.

CHARLAYNE HUNTER-GAULT: Mm-hmm. Now what about — there’s also individ-uals can deduct costs of nursing home and long-term care. Now tell me aboutthe importance of that.

SEN. EDWARD KENNEDY: Well, I think as all of us know the growing numbersof elderly in our communities, in our homes, we’re blessed with the factthat our parents are living longer, and I think in an ideal world, we wouldlike to have them have the option of either remaining at home or in a communitysetting so that they can remain at home in a community setting, or in termsof having nursing home help and assistance.

The amount of resources in a family that’s extended in the final severalmonths of one’s life are really extraordinary. And what we have tried todo, this program, is to try and provide through the tax program help andassistance to those families both in terms of getting insurance and beingable to cover some of those extraordinary expenses. It’s one of the areasof greatest concern, I think first of all to the parent, because the parentknows that they are draining the family’s resources and of course, theson or daughter knows that because they are seeing that they have to wantthe best in terms of the parent, the best in the care, and they’re worriedbecause they’re sacrificing the children’s future education.

So this, again, provides enormous tension and anxiety for those families,and this provides some relief. It doesn’t do all of the kinds of thingswe’d like, and let me just finally say I would hope that we can build onthis in the next Congress. We didn’t achieve all we would have liked, orat least I would have liked to have seen, that President Clinton wouldhave liked to have seen in the last Congress, but we’ve made a great progressin this one, and I hope we can continue the bipartisan effort, and thatwe can continue to make progress —

CHARLAYNE HUNTER-GAULT: Sen. Kassebaum, let me just ask you about thepart about the self-employed, who can buy insurance now, or get an increasein tax deductions. Explain that one, briefly to me and the significance.

SEN. NANCY KASSEBAUM: Yes, and also let me say on the long-term healthinsurance credit, this was something that Sen. Dole added, and which wasunanimously supported in an effort to encourage people to take long-terminsurance. This has been very expensive, and this will be a tax creditdesigned to encourage that people take that type of insurance. The self-employment —

CHARLAYNE HUNTER-GAULT: Excuse me. How much of a tax credit?

SEN. NANCY KASSEBAUM: What is that amount? I can’t think of what itis.

SEN. EDWARD KENNEDY: Well, it’s a modest credit, and it builds up overa period of years.

CHARLAYNE HUNTER-GAULT: Right.

SEN. EDWARD KENNEDY: It’s not going to offset the types of costs butit’ll help relieve, I suppose, people probably 30, 35 percent of the kindsof burden that they would have for maintaining someone in, in a nursinghome.

CHARLAYNE HUNTER-GAULT: All right. Let’s go —

SEN. EDWARD KENNEDY: But it’s the beginning of a program. I think itcould be built over a period of time. It’s constrained really because ofthe cost of it, but it’s a down payment; it can be expanded; hopefully,it will over a period of time.

CHARLAYNE HUNTER-GAULT: All right. Sen. Kassebaum, for the self-employed,yes.

SEN. NANCY KASSEBAUM: If you’re self-employed, currently you’ve beenable to deduct 30 percent of your insurance costs. Umm, this will now enableyou to deduct 80 percent. Umm, this is to balance what an employer candeduct 100 percent of the costs that they have to cover employees, forinstance, and this will be a balancing of fairness to those who have –are self-employed.

SEN. EDWARD KENNEDY: See, this has the larger employers are able totake the whole deduction. The small employers are not individuals, andwhat happens is you find out that in small businesses, as well as individual,they pay about 35 or 40 percent higher premiums. So they don’t get thefavorable tax treatment, they’re paying more, and it’s, it’s amazing tome that smaller businesses are, or individual, self-starting companiesprovide the coverage that they do.

CHARLAYNE HUNTER-GAULT: I understand that the Senate has just passedthis bill, and the House earlier and just a few minutes ago the Senatepassed it 98 to nothing, so what does that mean in terms of — Sen. Kassebaum,there’s a wonderful smile on your face, listening to that news.

SEN. EDWARD KENNEDY: Well, she should — if I can take — before sheanswers, under Sen. Kassebaum’s leadership, it passed unanimously in theCommittee a year ago today, it passed unanimously on the floor, and nowshe’s got a unanimous win.

CHARLAYNE HUNTER-GAULT: All right. Congratulations. When does this gointo effect, Sen. Kassebaum?

SEN. NANCY KASSEBAUM: July 1st of 1997.

CHARLAYNE HUNTER-GAULT: In other words, a year from now?

SEN. NANCY KASSEBAUM: Yes.

CHARLAYNE HUNTER-GAULT: Now, Senator, you said a few moments ago thatthis bill obviously doesn’t do everything that you wanted it to do, itdoes little for the 40 million people who don’t have insurance, there’sno equivalent coverage for mental health. Is legislation to cover thoseand other things likely to happen in the future? I mean, is there now amood to move on, on health care reform?

SEN. NANCY KASSEBAUM: I’m sure there is, and Sen. Kennedy, of course,has been a real pioneer in that. I am retiring at the end of my term thisyear, and Sen. Kennedy will be here to carry on. Sen. Domenici just todayintroduced legislation regarding mental illness and coverage for such.Both Sen. Kennedy and I have joined as co-sponsors, and there’ll be a hearingon that bill in September.

CHARLAYNE HUNTER-GAULT: Right.

SEN. NANCY KASSEBAUM: We’re also supportive of the 48-hour stay fornewborn mothers in the hospital, which Sen. Bradley has introduced, andwe are both supportive. So these are measures that are out there, I thinkdesigned to help in particular areas where there is a real need. And letme say on the legislation that we’re talking about that we’ve just passedand that’s upcoming, after having a clip of what you showed earlier, thisshows where bipartisanship can come together.

It’s not always easy, and we don’t always agree, and we can spend somecountless hours debating, but at the end of the day for the best interestof legislation that we felt was important, it did take bipartisanship,and that did come together, and I think that’s what made it successful.

CHARLAYNE HUNTER-GAULT: Great. Well, thank you both for joining us.

SEN. EDWARD KENNEDY: Could I just add — mental health has been thestepchild of our heath care system, so we hope we can make some progress.

CHARLAYNE HUNTER-GAULT: Thank you, Senator. Bye.

[END]

## Fish Oil for the Treatment of Crohn’s Disease

Heard about fish oil? This ill defined substance has gotten play in the popular health literature, but now there has been a study in Crohn’s disease published in the New England Journal of Medicine . The study showed that the preparation, Purepa, is effective. It should be available in a few years in the US.

There has been a fair amount of interest in fish oil as an antiinflammatory medicine over the years. In part this is driven by fish oil being “natural”. The scientific reason is that oils in the diet are the building blocks for certain chemicals the body makes, some of which are immune modulators. Fish oils contains a group of oils known as omega-3 fatty acids (chemically a double bond is present 3 down from the end of the carbon chain of the fat molecule). These oils are able to prevent the production of certain inflammatory molecules in the human body.

Fish oil per se is not a defined substance. There is the matter of variation of the fish, whether the oils is taken from whole fish sqeezings or just the fillets, and what processing is done. The whole fish issue is important because toxins (or perhaps useful drugs) are concentrated in fish livers. Processing is important because of stability. As with all supplements marketed as foods, the natural food pushers do not want regulation to be exerted upon them as it would add all sorts of complexities to their lives. As I see it, if they are going to push their own products, the consumer should be assured that the manufacturer can trace the source of raw material, have a regular way of making the stuff, keeps records of quality control, and does assays of the important ingredient(s). Additionally, the studies, if any, used to support the use of natural products often are used to recommend products different from those in the study. With something as unregulated, unassayed, and undefined as health food store products, who knows whether the health food store drug will do any good.

With this background, now comes a drug which is a fish oil preparation. Researchers in Italy used a fish oil preparation called Purepa, manufactured in Sweden, and coated the capsules with an enteric coating called Eudragit NE 30D. It is well defined and manufactured with the care a drug company takes. A study in the New England Journal of Medicine (NEJM 334(24):1557-1560, 13 June 1996) reported that patients with Crohn’s disease had less relapses when taking the medicine than did those taking placebo. The study was well done. It used a group of patients randomly assigned to either drug or placebo. Patients were not able to tell which drug they were on. (Which also implies that enteric coated Purepa does not have the nasty fish taste which can make fish oil hard to take.) The patients who were asked to participate were known to have a high chance of flares of the disease, based on their having all been in remission less than 2 years, with serum alpha 1-acid glycoprotein concentration > 130, alpha 2-globulin > 0.9, or a sed rate > 40. The findings were remarkable. The patients on drug had a relapse rate of only 41% compared to controls who had a relapse rate of 74% over the one year of followup. Diarrhea was a side effect in 4 of 39 fish oil treated patients vs 1 of 39 placebo patients. The diarrhea did not resolve when the drug was stopped in experimental or control subjects. The dosage of fish oil was 9×500 mg capsules per day, = 4.5 grams of fish oil per day. Interestingly, all relapses occurred within 7 months in both groups. Also, the fish oil group had improvement in all three serum measurements made, while the placebo group all had worsening of the measures.

The problems with the study concern whether the drug will be effective in all patients with Crohn’s, or only those patients like those in the study. This is a real issue – Crohn’s disease is a heterogeneous group, and the Italian group that published this may have selected a subset of Crohn’s that would respond differently. Also, this study was done in Italy. The Italian diet differs from a typical American diet, not to mention Scottish, New Zealand, Chinese, Dutch, Polish, German, French, or any cuisine that you may wish to identify. Italians also are heterogeneous in their diet, varying greatly from North to South, and inland vs seacoast. The study did not subgroup its results by region of Italy where subjects were born or lived, which would have been interesting.

It looks like this will be effective, however. Given the safety of the preparation it will be a welcome addition to treatment of Crohn’s. The variation in fish oil preparations available, along with the history of previous negative studies with fish oils, leads me to conclude that until a particular preparation is studied it will not be possible to say whether any particular fish oil preparation will work in Crohn’s. It is interesting that both placebo group and Fish Oil group had no more relapses after 7 months. It would be nice to know if the changes in any of the blood measures predicted who would relapse. The relapse curves also raise the question whether patients only need to be on the drug for 7 months to get the full benefit.

Stephen Holland, M.D.
University of Illinois College of Medicine at Urbana-Champaign

## cA2 in Crohn’s disease

What is the “cure” for Crohn’s that has been reported in the news? There have been reports of an antibody that can treat Crohn’s disease. While not a cure, it may represent a new treatment that will more rapidly bring flares of Crohn’s under control.

[ The IBDPage has been around for a long time. Remicade (infliximab | Janssen) was the first anti-TNF drug available. Take this post as an interesting post from long ago – Ed.]

cA2 in Crohn’s disease

A fair amount of press has recently been seen about a new cure for Crohn’s disease. Unfortunately, this was very poor reporting. The drug that has garnered all this attention was called cA2, and now is named Infliximab. This drug is an antibody that binds an immune chemical called TNF-alpha. Antibodies are large proteins that can only be administered intravenously.The reports at the Digestive disease week meeting in San Francisco lastMay (May 1996) basically showed that in patients with severe Crohn’s disease,65% percent had an excellent response to administration of cA2. Patientswith Ulcerative colitis were not helped. Patients relapsed as the drugwore off.

Thus, while not a cure, cA2 will probably be an important drug in the treatmentof Crohn’s disease. It will probably find its role in the treatment ofpatients with Crohn’s who are hospitalized for a severe flare. In thesepatients, the drug will probably allow faster control of the inflammation.The patients will still be treated with steroids, but the cA2 will allowfaster discharge. Interestingly, a lot of patients getting the drug at this time are patients who have been maintained as an outpatient who havebeen doing poorly with chronic fistulas or inflammation that has nevercome under control.

One aspect which has cause a lot of excitement in the scientific communityabout this drug is that it is one of the first success stories for immunologyresearch predicting clinical results. TNF-alpha is an early player in theimmune response, so blocking it should be effective. However, studies ofUlcerative Colitis patients showed that they do not have elevated levelsof TNF-alpha, while Crohn’s patients do. Thus, the effectiveness of cA2in Crohn’s but not in UC confirmed the immune studies in those patients.The research into what causes the lack of response in 35% of the Crohn’spatients will be interesting to follow.

Stephen Holland, M.D.
Section of Clinical Pharmacology
University of Illinois College of Medicine at Peoria

## Salmonellosis Associated with a Thanksgiving Dinner

Many will enjoy eating turkey on Christmas. (Perhaps some on Hanukah – is turkey Kosher?) Some tips from the CDC on cooking can be found in this chilling report on a family that had a bacterial infection from Thanksgiving dinner.

The turkey can kill you.

The following is from the CDC’s MMWR publication. The MMWR can be downloaded from ftp://ftp.cdc.gov/pub/Publications/mmwr/wk/

### Salmonellosis Associated with a Thanksgiving Dinner

MMWR Morb Mortal Wkly Rep. 1996 Nov 22;45(46):1016-7.

On November 28, 1995, the county coroner’s office notified the ClarkCounty Health District in Las Vegas, Nevada, about a death suspected tohave resulted from a food-borne disease. This report summarizes the investigationof the outbreak of gastroen-teritis among persons who attended a Thanksgivingdinner. The investigation documented Salmonella serotype Enteritidis (SE)infection associated with eating improperly prepared turkey and stuffingcontaining eggs and emphasizes the need to use a meat thermometer to ensurecomplete cooking of turkey and stuffing.

During November 25­-28, 1995, all six persons who attended a Thanksgivingdinner at a private home on November 23 and a seventh person who on November25 ate food remaining from the dinner had onset of abdominal cramps, vomiting,and diar-rhea. Two persons were hospitalized because of dehydration; athird person was found comatose at home and died from severe dehydrationand sepsis. Stool cultures obtained from three persons, including the decedent,yielded SE phage type 13a. Turkey and stuffing were the only foods eatenby all seven ill persons. No leftover food was available for culture.

The Clark County Health District interviewed the ill persons (includingthe cook) to obtain details about the preparation and cooking of the turkeyand stuffing. On No-vember 22, a 13-pound frozen turkey was thawed for6 hours in a sink filled with cold water. After thawing, the packet ofgiblets (heart, liver, and gizzard) was removed, and the turkey was storedin a refrigerator overnight. However, on November 23, parts of the turkeywere noted to be frozen. The turkey was filled with a stuffing made frombread, the giblets, and three raw eggs, and then placed for 1 hour in anoven set at 350 F (177 C). The setting was lowered to 300 F (149 C) whilethe turkey cooked for an estimated additional 4 hours. The turkey was removedfrom the oven when the exte-rior had browned. A meat thermometer was notused. The stuffing was removed im-mediately and was served with the turkey.After the outbreak, health officials tested the oven set at 300 F (149C) and found the temperature to be 350 F (176 C).

Reported by: O Ravenholt, MD, CA Schmutz, LC Empey, DJ Maxson, PL Klouse,AJ Bryant, Clark County Health District, Las Vegas; R Todd, DrPH, StateEpidemiologist, Nevada State Health Div. Foodborne and Diarrheal DiseasesBr, Div of Bacterial and Mycotic Diseases, National Center for InfectiousDiseases, CDC.

Editorial Note: An estimated 2­4 million cases of salmonellosisoccur each year in the United States, resulting in at least 500 deaths( 1 ). Approximately 40,000 of these in-fections are culture-confirmed,serotyped, and reported to CDC through the National Salmonella SurveillanceSystem. In 1995, SE was the most common serotype reported, accounting for25% of the 40,720 serotyped culture-confirmed cases. Salmonellosis is frequentlyassociated with eating undercooked eggs and poultry. Undercooked eggs area particularly common source of SE infections.

During 1988­ 1992, among foodborne disease outbreaks of salmonellosisreported to CDC in which a single food item was implicated, consumptionof turkey and eggs accounted for 4% and 14% of cases, respectively. Inaddition, eggs or foods containing eggs as a princi-pal ingredient caused64% of the SE outbreaks ( 2 ). Factors probably associated with the outbreakdescribed in this report included inadequate thawing, use of raw eggs inthe stuffing, and undercooking; in addition, the browned color of the turkeymay have caused the cook to believe that the turkey andstuffing were thoroughlycooked. Although the original source of the Salmonella is unknown, theraw eggs used in the stuffing probably contained SE, and these eggs probablywere incompletely cooked; undercooking may occur more commonly in tur-keysthat contain stuffing (J. Carpenter, Ph.D., University of Georgia, personalcommu-nication, 1996).

Each year, an estimated 45 million turkeys are eaten in the United Statesat Thanks-giving (J. DeYoung, National Turkey Federation, personnel communication,1996). Salmonella infection may result from eating improperly cooked turkeyand stuffing ( 3,4). This risk for infection can be reduced by cookingstuffing outside the turkey. Guidelines prepared by the U.S. Departmentof Agriculture (USDA) for persons who choose to cook stuffing inside theturkey recommend preparing the stuffing immediately before it is placedinside the turkey, stuffing the turkey loosely, inserting a meat thermometerinto the center of the stuffing, and ensuring that the thermometer attainsa temperature of at least 165 F (74 C). Additional recommendations forsafely preparing and cooking a turkey include thawing the turkey completelybefore cooking, cooking in an oven set no lower than 325 F (163 C), andusing a meat thermometer to ensure that the innermost part of the thighattains a temperature of 180 F (82 C). Although the set temperatureand cooking time can be used as guides to determine whether food is completelycooked, inaccuracies in the actual temperature and incomplete thawing beforecooking can lead to undercooking. Use of a meat thermometer provides amore accurate determination of thorough cooking. Further advice on cookingturkeys and stuffing is available from USDAÕs Meat and Poultry Hotline,telephone (800) 535-4555.

References

1. Cohen ML, Tauxe RV. Drug-resistant Salmonella in the United States:an epidemiologic perspective. Science 1986;234:964­9.

2. Bean NH, Goulding JS, Loa C, Angulo FJ. Surveillance for foodborne-diseaseoutbreaks United States, 1988­-1992. In: CDC surveillance summaries(October). MMWR 1996;45(no. SS-5).

3. CDC. Foodborne nosocomial outbreak of Salmonella readingÑConnecticut.MMWR 1991;40: 804­6.

4. CDC. Restaurant outbreak of salmonellosis due to undercooked turkey Washington. MMWR 1978;27:514,519.

Stephen Holland, M.D.
Section of Clinical Pharmacology
University of Illinois College of Medicine at Peoria

## Heparin in IBD

Here is an overview and several abstracts about heparin in IBD

One of the oddest treatments to come along in quite some time is the use of a medicine called heparin in the treatment of IBD. The reason this is so odd is that heparin is one of a number of drugs known as anticoagulants. In someone with a disease that causes bleeding it is surprising that ananticoagulant would not make things worse.

Historically, the main drug used in ulcerative colitis was discoveredaccidentally. Sulfasalazine (aka Azulfidine) was initially designed asan antiarthritis drug. It is a molecule of 5-ASA and sulfa antibiotic joinedby a covalent bond. The initial thinking was that the drug would be absorbedand the combination of antibiotic and antiinflammatory would be good forrheumatoid arthritis, a disease that back then was thought to be due toan infection and inflammation. A few patients with UC and arthritis wereseen to do quite well in regards to their colitis. It didn’t work verywell against the arthritis. Turned out that the drug is not well adsorbed,and that in the colon the drug was broken down by bacteria (hooray forbacteria) and locally liberated the antiinflammatory drug 5-ASA.

History seems to have repeated itself with heparin. A patient with UCwas being treated for a blood clot in the leg. Their intrepid physician,knowing that DVT’s could be life threatening, went ahead and used heparin.The patient’s UC improved. Thus the use of heparin in UC had its beginnings.

Further support for the use of heparin in UC is that the microscopicappearance of the tissue is that of multiple tiny blood clots in the vesselsof the injured colon. This was thought to represent coagulation in responseto the inflammation, and perhaps was even protective since clotting mayhave represented the prevention of further bleeding. Well, with the improvementthat was seen, it was only natural to wonder whether the improvement seenin the patients with UC might have been due to better blood flow to theinjured tissue.

A number of patients have now been given heparin during attacks of UC.It seems to work. The abstracts below describe the responses that patientsseem to have. Interestingly, one of the described uses is in patients withextraintestinal complications of IBD, such as erythema nodosum. These complicationscan be very slow to respond to conventional therapy. Bleeding does ometimeshappen, but it does not seem to be uncontrollable. Heparin has no toxicity,and only occasionally has poor outcomes, though as more patients are treatedwe may see injuries occur (massive GI or pulmonary bleeding, strokes).

Below I have reproduced the abstracts from the 1996 DDW meeting thatreferred to heparin in treatment of IBD. They are copyright DDW.

Remember that these are early studies, and a number of treatment forIBD have been found to be worthless over the years. Even if correct, thestudies were small, and did not have controls. There is no data on whatthe optimal dose or duration of treatment is. Even simple things, liketaking advantage of what is known about the histology of UC and checkingwhether the presence of microthrombi predicted whether patients would benefit was not done. Most patients seem to be helped, but a few seem to bleedmore. Can we predict who those will be? These questions will need to beaddressed before heparin moves into the mainstream of treatment of IBD.

TITLE: [65] HEPARIN THERAPY IN REFRACTORY ULCERATIVE COLITIS – AN UPDATE.

AUTHORS: P.R. Gaffney, A. Gaffney. Dept. of Surgery, Mallow GeneralHospital, Mallow, Co. Cork, Ireland.

BODY: Aims and Methods: At the 1993 meeting of the AGA we reported a beneficial effect associated with heparin therapy in nine of ten cases with refractory UC. As a number of initially promising treatments for IBD have subsequently proved disappointing, we decided to review (a) the outcome of the patients in our pilot study, (b) unpublished case reports of further patients treated with heparin, and (c) recent publications on heparintherapy in refractory UC.

Results: (a) Five of the nine patients who went into remission on heparin had a recurrence off heparin; four of these responded to further heparin treatment. Three patients had colectomies (for cancer; obstruction; pseudopolyps). All three were in clinical remission at the time ofsurgery. (b)Seven further patients with refractory UC were treated at our hospital. Three had fulminant and four moderate disease. All went into remissionon i.v. heparin with sulphasalazine, two having initially failed to respondon s.c. heparin. We received reports of nine cases of UC treated with heparin at other centers here and abroad, seven of whom had a favorable response. (c)an open pilot study of heparin in nine cases of refractory UC reports remission in seven cases, with one relapse[1]. A case study [2] reportsthe rapid and sustained resolution of pyoderma gangrenosum and refractoryUC on
i.v. heparin. Conclusions: Heparin, used i.v. and with sulphasalazine, appears to be effective in the treatment of refractory UC, and warrants larger controlled trials.

1. Evans RC, Rhodes JM.Treatment of corticosteroid resistant ulcerative colitis with heparin -a report of nine cases (abstract). Gut 1995;37(supp1 2);A49.

2. Dwarakanath AD, Yu LG, Brookes C, Rhodes JM. ‘Sticky’ neutrophils, pathergic arthritis, and response to heparin in pyoderma gangrenosum complicating ulcerative colitis. Gut 1995;37:585-588.

TITLE: [65] TREATMENT OF ULCERATIVE COLITIS WITH HEPARIN

AUTHORS: F. Brazier1, T. Yzet1, A. Boruchowicz , J.F. Colombel , J.C.Duchmann1, J.L. Dupas1. Department of Gastroenterology, University Hospital,Amiens1, Lille , France

BODY: Activation of procoagulant factors and high incidence of
thromboembolic events observed in ulcerative colitis (UC) suggest thata disorder of coagulation may contribute to the pathogenesis of thisdisease. Preliminary studies have shown that clinical remission may be obtainedby heparin treatment in UC.

The aim of this study was to evaluate on a small group of patients,the efficacy of heparin in active UC.

Methods: 6 patients (2 F, 4 M; age 20-43 yr) with active UC were included in this open label study. Disease activity was established at entryby clinical and colonoscopic criteria. Disease extent was left-sided in 3 patients and extensive to the entire colon in the 3 other patients. UC was moderately active in 4 patients and severe in 2 patients ;3 patients failed to respond to corticosteroids given for at least 2 weeks. Patients were administered heparin, either intravenously (IV) 3000u/4hrs for 1 weekand subcutaneously (SC) (calcium heparinate) 0.1ml/10kg b.i.d. for the 3 following weeks (n=3), or SC 0.1ml/10kg b.i.d. for 4 weeks (n=3). Concomitant treatment with other drugs was not allowed during the study.
Patients were clinically evaluated daily.

Results: 4 patients reported significant clinical improvement: rectal bleeding stopped within the first 3 days and a remarkable decreasein bowel movements was observed in less than 10 days. One patient did not improve and proceeded to colectomy after 1 week. In the last patient heparin treatment was discontinued after 5 days because of a skin allergic reaction. Colonoscopy performed after 4 weeks in the 4 responders showed a complete healing of mucosal damages in 3 patients but persistent superficial erosions in one. Three of these 4 patients were still in clinical remission 4 weeks after the end of heparin treatment.

Conclusion: These preliminary results indicate that heparin treatmentmay be effective in acute UC.

TITLE: [65] EFFECT OF HEPARIN TREATMENT ON EXTRAINTESTINAL MANIFESTATIONSASSOCIATED WITH INFLAMMATORY BOWEL DISEASES.

AUTHORS: F. Brazier, T. Yzet, J.C. Duchmann, F. Iglicki, J.L. Dupas.Department of Gastroenterology, University Hospital, Amiens, France

BODY: Extra-intestinal manifestations occurring in patients with Crohn’s disease (CD) or ulcerative colitis (UC) are related to the activityof the bowel disease. Microvascular inflammation and hypercoagulable statemaycontribute to the pathogenesis of active inflammatory bowel disease(IBD).Preliminary studies have suggested that heparin, acting by anti-inflammatoryand anticoagulant properties, may be effective in the treatment of activeUC. The aim of this study was to evaluate the efficacy of heparin treatmenton extra-intestinal manifestations associated with active IBD. Methods:Thestudy was undertaken in 7 patients (5 F, 2 M, age 25-35 yr) with activeIBD(6 CD, 1 UC) and one (n=5) or more (n=2) extra-intestinal manifestations(erythema nodosum n=4, pyoderma gangrenosum n=1, peripheral arthritis n=3, apthous stomatitis n=1). These manifestations were associated with flare ofbowel disease in 6/7 patients. Three patients had chronic active CD treatedby prednisolone (20-35 mg/d) for at least 3 months; prednisolone doses werenot altered in the 3-weeks period before and were to be maintained at thesestable doses throughout the 4-weeks study period. Patients wereadministered heparin, either intravenously (IV) 3000u/4hrs for 1 week and subcutaneously (SC) (calcium heparinate) 0.1ml/10kg b.i.d. for thefollowing 3 weeks (n=2), or SC 0.1ml/10kg b.i.d. for 4 weeks (n=4).Concomitant treatment with other drugs was not allowed during the study.Clinical evaluation was performed every week during the treatment,andevery 2 weeks for 3 months after the end of heparin treatment. Results:Extra-intestinal manifestations vanished completely in 5/7 patients withinthe first 2 weeks. In 1 patient erythema nodosum improved but did notvanish completely; for one patient with pyoderma gangrenosum, heparin treatment had to be discontinued after 5 days because of a skin allergic reaction. In 2 responders, erythema nodosum recurrence was observed within2 weeks after the end of heparin treatment. In the 5 responders, the meanC-reactive protein level remarkably decreased from 108 mg/l beforetreatment to 31 mg/l after 1-week treatment. Conclusions: These resultsindicate that heparin may be a potential therapeutic drug forextra-intestinal manifestations in the treatment of active IBD.

TITLE: [65] TREATMENT OF ACTIVE CROHN’S DISEASE WITH HEPARIN

AUTHORS: J.L. Dupas, F. Brazier, T. Yzet, B. Roussel, J.C. Duchmann,F. Iglicki, Department of Gastroenterology, University Hospital, Amiens,France

BODY: It has been suggested that microvascular thrombosis related to vasculitis and procoagulant factors activation may contribute to the pathogenesis of Crohn’s disease (CD). Anticoagulant and anti-inflammatory properties of heparin may be useful in the treatment of active inflammatory bowel diseases. The aim of this study was to investigate the potential efficacy of heparin in the treatment of active CD. Methods: 13 patients(9F, 4 M; age 16-31 yr) with active CD (Crohn’s disease activity index,CDAI> 200) were included in the open-label study. Disease activity was clinically and endoscopically assessed before treatment. Disease extended only to the colon in 3 patients and to the colon and terminal ileum in the10 other patients. Eight patients had chronic active CD treated by azathioprine and/or prednisolone for at least 3 months; drug doses were not altered in the 3 weeks period before and were continued at the dose used at entry, throughout the 4-weeks study period. Patients were administered heparin, either intravenously (IV) 3000u/4hrs for 1 week and subcutaneously(SC) (calcium heparinate) 0.1 ml/10kg b.i.d. for the following 3 weeks(n=7), or SC 0.1 ml/10kg b.i.d. for 4 weeks (n=6). Concomitant treatment with other drugs was not allowed during the study. All patients were clinically and biologically evaluated every week for the 4-weeks treatment period and followed up every 2 weeks for 2 months after the end of heparin treatment. Results: After 4-weeks treatment, 7/13 patients (54 %) fulfill the remission criteria (CDAI < 150) and 3 other patients reported significant clinical improvement ([Delta-bar] CDAI>100); 3 patients failed to respond. The mean CDAI decreased from 315 (95%CI:260-369) before treatment to 165 (95%CI:107-222) at the end of heparin treatment (p<0.004).The mean C-reactive protein decreased from 80.5 mg/l (95%CI:45-115) before treatment to 35 mg/l (95%CI:18-52) (p<0.007) after 1-week treatment.Slight increase of rectal bleeding due to overdosage of heparin was observed in 2patients leading to discontinuation of treatment in one of them. Among responders, 6 patients were still in remission 3 months after the end of treatment and 1 patient had a relapse at week 6. Conclusions: These results suggest that heparin treatment may be effective in patients with active CD.

TITLE: [65] EFFECT OF HEPARIN ON INTERLEUKIN-6 AND TUMOR NECROSIS FACTOR-alpha SERUM LEVELS IN INFLAMMATORY BOWEL DISEASES.

AUTHORS: F. Brazier1, T. Yzet1, C. Dessaint , J.C. Duchmann1, L. Prin, J.L. Dupas1. Departments of Gastroenterology1, Immunology, University Hospital, Amiens, France.

BODY: It has been suggested that pro-inflammatory cytokines interleukin-6(IL-6) and tumor necrosis factor – alpha (TNF-alpha) may be involved in the pathogenesis of inflammatory bowel diseases (IBD). In a preliminary study conducted to evaluate the effectiveness of heparin treatment in IBD,we obtained a clinical remission (CDAI<150) in 7/13 (54 %) patients and a significant improvement ([open square]CDAI>100) in 3/13 (23 %) patients with Crohn’s disease (CD) as well as a clinical remission in 4/6 patients with acute ulcerative colitis (UC).

The aim of this study was to evaluate the effect of heparin treatmenton IL-6 and TNF-alpha serum levels in IBD.

Methods: IL-6, TNF-alpha (ELISA) and C-reactive protein (CRP) serum levels were measured before and after 1-week heparin treatment in 12 patients with active IBD (8CD, 4 UC). Patients received heparin, either intravenously 3000u/4hrs or subcutaneously (calcium heparinate) 0.1 ml/10kg b.i.d.

Results: table shows mean values and the results of paired comparison of CRP, IL-6 and TNF-alpha serum levels for the 12 patients:

             normal   before     after   p-value
treatment   1 week
CRP mg/l      < 5      79         36     <0.02
IL-6 pg/ml  3-8.5    74.3       42.0     <0.02
TNFα pg/ml  3-20     40.8       27.9     <0.15


Conclusion: High values of IL-6, and TNF-alpha serum levels are observed in acute IBD. IL-6 but not TNF-alpha decreases significantly after 1-week heparin treatment.

TITLE: [65] HEPARIN IN THE TREATMENT OF HIGHLY ACTIVE INFLAMMATORYBOWEL DISEASE (IBD).

AUTHORS: C. Folwaczny, M. Spannagl, W. Wiebecke*, M. Jochum#, W. Heldwein,K. Loeschke. Medizinische Klinik, Klinikum Innenstadt, Pathologisches Institut*,Abteilung für klinische Biochemie#, Ludwig-Maximilians University,Munich, Germany

BODY: Recently (Gaffney et al., Am. J. Gastroenterol. 1995, 90: 220) unfractioned heparin (UH) was reported to be clinically helpful in 10patients with steroid-resistant ulcerative colitis (UC). It is not known whether this beneficial effect is mediated by anti-coagulatory or anti-inflammatory properties of UH. Therefore, we started an openun controlled trial to investigate the clinical and antiinflammatory effects of UH in patients with highly active IBD. Patients and methods: So far 6 UC patients and 1 patient with Crohn’s disease (CD) (2 women, 5 men; mean age:31+-3 y; mean duration of the disease: 10+-4 y) were studied. At entry UC patients had a mean clinical activity index (CAI, according to Gomeset al.) of 17+-3 points and the CD patient had a Crohn’s disease activity index(CDAI, according to Best at al.) of 425 points. The mean follow-upper iod was 5 weeks. The protocol includes PTT-effective i. v. application of UH(>60 sec.) for 2 wk followed by s. c. UH (12.500 I. E. BID) for another6wk. In addition, sulfasalazine (1 g/TID) was given orally. Prednisolone in the 6 UC-patients could be tapered from 38+-7 mg/day at study entry to 26+-10mg after 4 wk. Erythrocyte-sedimentation rate (ESR), C-reactive protein(CRP), white-blood cell (WBC) and platelet count (PC), \alpha_1 and\alpha_2-globulin and fibrinogen were monitored weekly. Results: All patients showed marked clinical improvement. After 2 and 4 wk the CAI decreased to a mean of 5+-1 points and 5+-1 points (p<0,01), resp. and the CDAI decreased to 229 and 250 points, resp. Rectal bleeding stopped in all patients within 4 wk.

The laboratory values at study-entry, after 2 and 4 wk resp. were asfollows:

       baseline         2wk                 4wk
ESR:    77+-8       43+-6   (p<0,01)  47+-9 mm/2h   (p<0,01)
CRP:    12+-4        2+-1   (p<0,01)   2+-0,5 mg/dl (p<0,01)
WBC:  14.0+-2.0   10.0+-1.2 (p<0,01) 9.0+-1.3/ l    (p<0,01)
PC:    448+-34     387+-47  (p<0,01) 330+-44/ l     (p<0,01)
\alpha_1-globulin:
5,3+-0,9    3,8+-0,6 (p<0,01) 5,0+-0,6%
fibrinogen:
379+-12     290+-37  (p<0,01) 317+-32 mg/dl

The CD patient refused corticosteroids and arthritis resolved after 6 wk. In 1 UC-patient UH treatment was stopped at day 11 because of sudden worsening of the rectal bleeding (PTT at this time <60 sec.) necessitating blood transfusions. Because the patient noticed a decrease in bowel movements i. v. UH was restarted after 2 days, resulting in continuing improvement with no further bleeding. No other unwanted effects were seen, apart from a minor reversible increase in ALT-activity in 3 patients. Conclusions: These preliminary data confirm that UH could be useful in highly active IBD. This effect may in part be due to anti-inflammatory properties of UH. However, controlled trials have to be awaited before routine use of UH can be recommended.