Clinical data not surprising, cost data may be misleading...The question is when to use Remicade and in whom.

Implications: The clinical outcome information in this report regarding decreasing colectomy rate is not particularly surprising, but the cost statements may be misleading.  One wonders if the increased health care costs in the colectomy group reflect that fact that the observation period was only twelve months, and is skewed because of issues involving the immediate post-op period.  One should be looking at cost related issues in the long run, and would expect that five years down the line, for example, given the costs involved with drug therapy and monitoring patients with IBD and the fact that colectomy in UC is curative, the costs in the colectomy group would be significantly lower.  Remicade has been an important addition in how we treat inflammatory bowel disease for some time, and has been FDA approved for use in UC for several years now. It has allowed us to not only get more patients into remission, but also keep patients in remission and decrease steroid usage.

Analysis: It would be hard to believe that in the long run, colectomy would not be cost effective vs continued medical therapy.  Colectomy might be more expensive in the short run (i.e. twelve months), but most likely not in the long run.  What is more important is that the drug has the potential to reduce disease related morbidity, improve quality of life, decrease steroid usage and morbidity, and have a positive effect on clinical outcomes. 

The larger issue is when to start the drug, and in whom, as initiating Remicade is a signficant  committment, and is certainly not without risks.   One is often dealing with young patients, often of child bearing age, and making a decision to use Remicade either for induction and/or maintenance has major implications.  One has to carefully weigh benefits and risks when deciding to use this drug.  That being said, the drug is effective, and if used appropriately, has the potential to significantly improve clinical outcomes.  In the next several years, we will have the choice of a number of biologic agents to utilize in our inflammatory bowel disease patients (Humira is already FDA approved for Crohns disease, for example), and understanding the best way to utilize these drugs will become increasingly important.