Flare, Med Change?? - Opinions and Advice Please

Hi Everyone,

Looking for some advice and opinions on my current situation. I'll try to keep this short with relevant details.

Started Humira in December, 2016 bi-weekly. After 12 weeks felt that I was in "clinical" remission but colonoscopy in early March revealed mild inflammation in the cecum. Changed dosing to weekly and had a great run with remission. In October, the D and urgency started creeping in but no blood and no mucous. The frequency crept up to an average of 7 times per day. Saw my GI, did stool studies (bacteria, C-Diff, Ova and Parasites, Isospora, Microsporidium, Cyclospora) all negative. Blood work looks fine, which it always does even when flaring. Adalimumab Level is 12 ug/mL, results higher than 0.6 ug/mL which is in the therapeutic range for mucosal healing (at least for CD); antibodies undetected.

At my appointment we discussed the various options pending the test results. If there were antibodies I would move to Simponi and add methotrexate. I had a reaction to Imuran so he thought this would be a better option than 6-MP. If the level of adalimumab was too low (ie metabolizing the med to quickly) I would move to Entyvio. Or, best case was a bacterial infection and we would treat and move on.

So here's where I need advice and your experiences. My levels are fine, I don't have antibodies and no bacterial infection. Where do I go from here? I always flare in the fall and this flare, in my opinion, is mild. I have a 30 day script for Uceris and cort-enemas and feel better already. Do I stay on these for 30-60-90 days and treat the flare as a fluke? Do I change meds and consider Humira a failure? Should I add methotrexate which I really don't want to do due to side effects and don't know if it would even help as I don't have anti-bodies? I am due for my annual scope in early March.

BTW - thanks Quincy and i-Poop for you great advice regarding rectal meds. They are truly the best way to hit inflammation directly and quickly.

Any advice or guidance or what you have done would be greatly appreciated.

Side note, I am afraid to give up on Humira so soon as that leaves me with 3 FDA approved biologics, although Xeljanz is supposed to be approved for UC in mid 2018 and Stelara may be an option for off-label.

Thanks iPoop. I guess in my mind I know that's the proper route. I'm not ready to give up on Humira as it's quick, convenient and easy and I have zero side effects. That's probably the best option than I will know if any new side effects are the mtx.

Do you know why they recommend an injection of mtx as opposed to a pill form? I forgot to ask at my appointment. I guess if I already do a shot a week what's another in the grand scheme thing of things. Also, he recommended taking folic acid for 6 days of the week and not on injection day. The mtx depletes the body of vitamin b and that helps with the nausea but I am curious on why they don't have you take it on injection day. Any thoughts on that one?

Thanks for putting an end to my little denial game, you the one where you start flaring and say, I don't see any blood so maybe it's IBS or I have a stomach bug or one of a thousand other lies we try to tell/sell ourselves. Or maybe that's just me!!!

Thanks FlowersGal, glad to hear that you are doing well on Entyvio. So the folic acid is a prescription, I guess I just assumed I would buy it OTC. I'm glad you also stated you didn't have any side effects, maybe I'll get lucky in that regard.

I'm no expert on methotrexate, as far as why go IV versus pill form.

So, I'd ask on the Crohn's board as they use it a lot more extensively than us UCers do. Methotrexate is a common Crohn's drug. /www.healingwell.com/community/default.aspx?f=17

I do know that MTX is a very fast working immunomodular, unlike the imuran/6mp which take forever to work...

I think I would stay with the Humira. I was on mtx and had no side effects as long as I took the folic acid, its important. I took 5mg a day which is the max dose for 2 weeks and then reduced it to 3mg a day. I even took it on the day of taking mtx as doctors cant agree on whether thats good or bad.