Long-term experience with 6-mercaptopurine in the treatment of Crohn's disease.

We report our observations after 20 yr of clinical experience with 6-mercaptopurine (6-MP) in 148 patients with Crohn's disease who had not satisfactorily responded to steroids and other drugs. Specific therapeutic goals were established for each patient, and the NFIC (now CCFA)-IOIBD index of Crohn's disease activity was calculated pre- and post-therapy. Defined therapeutic goals were achieved in 68%. Major successes include 1) elimination of steroids (66% p < 0.001); 2) healing of internal fistulas and abscesses or improvement by elimination of discharge and tenderness (64% p < 0.05); and 3) healing or improvement by elimination of pain, tenderness and discharge of perirectal fistulas and abscesses (87%, p < 0.05). Other therapeutic goals which achieved 100% success were 1) healing or marked improvement of Crohn's disease of the stomach and duodenum; 2) permitting surgery to be performed electively after 6-MP allowed margins for surgical resection to be delineated. 6-MP was less effective in achieving the therapeutic goals of preventing recurrent small bowel obstruction (43%) and elimination of abdominal masses (55%). Seventy-eight percent of patients showed a reduction in the activity index with a mean of 43% (95% C.I. 36-51%). 6-MP was once again demonstrated to be effective in achieving major therapeutic goals in two of three patients with severe Crohn's disease. Accordingly, the need for surgical resection and subsequent extension of the disease is often postponed or eliminated.

The safety of corticosteroid therapy in Crohn's disease with an abdominal mass.

Steroid therapy is often avoided in the Crohn's disease patient with a palpable abdominal mass, for fear of dissemination of infection, should the mass prove to contain an abscess. In the present study, 24 patients with Crohn's disease and a palpable abdominal mass were treated with high dose steroids. In 15, the mass resolved completely and, in another nine, it decreased in size by at least 50%. Fourteen of 24 patients eventually required resection for persistence or recurrence of Crohn's disease activity with or without the abdominal mass, but in all the operation was performed electively. At least eight patients never required resection during a mean follow-up period of 40 months. In 13 patients, the mass was later proved to actually contain an abscess cavity. No complications attributable to steroid therapy were seen in either the operative or nonoperative group. Clinicians should not fear using high dose ACTH/corticosteroids to treat severe Crohn's disease with an abdominal mass, if indicated, as it is both safe and effective whether an abscess cavity is present or not.

The therapeutic efficacy of 6-mercaptopurine in refractory ulcerative colitis.

We report our observations over 18 years (1970-1988) on 81 compliant patients with resistant ulcerative colitis who received 91 courses of treatment with 6-mercaptopurine (6-MP) for at least 4 months. These represent 172 patient years of 6-MP therapy and 308 years of observation after initiating 6-MP. In all patients, treatment with sulfasalazine and steroids had failed; most (96%) were dependent on systemic steroids and still symptomatic. The mean treatment period with 6-MP was 1.8 yr. In 42 out of 87 courses (48%) of 6-MP steroids could be eliminated, and in another 11 (13%) could be significantly reduced, for a total response rate of 61%. When four patients not on steroids were included, the response rate was 63%. The steroids were discontinued after a mean treatment time of 10 wk, and the 42 patients remained steroid free for the remainder of 6-MP treatment. Follow-up data after discontinuing 6-MP in 29 patients from this group show the mean time to relapse was 21 months with a median time of 12.5 months. We conclude that 6-MP is effective in inducing remission, eliminating steroids, and maintaining remission in many patients with refractory ulcerative colitis. Patients should be made aware of this option before colectomy is recommended.