My brother has Crohn's disease. How to treat his low B12 level?

Question

Hello doctor,

My younger brother, aged 23, was diagnosed with Crohn’s disease last month after an MRI enterography showed terminal ileum thickening. I have a few concerns:

He is taking Azathioprine and Budesonide. How long does it usually take to see improvement?
Also, are there any warning signs that indicate the disease is flaring again?
His CRP was 26, and his vitamin B12 was quite low. Should we give B12 injections regularly in such cases?
Is there any special diet that helps reduce inflammation or avoid recurrence?
We are also worried about side effects from Azathioprine. How often should his liver and WBC counts be checked during treatment?

Kindly suggest.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

A new diagnosis of Crohn’s disease at the age of 23 can feel sad for the whole family, but you should know that with proper treatment and monitoring, many patients achieve good control and live a normal life.

First, regarding how long it takes to see improvement, Budesonide is a corticosteroid that works relatively quickly to reduce inflammation, especially in mild to moderate ileocecal Crohn’s disease.

Many patients begin to notice symptom improvement within one to three weeks, though full response may take up to six to eight weeks.

Azathioprine is an immunomodulator used for long-term control and prevention of relapse. It works much more slowly. It typically takes eight to 12 weeks, sometimes up to three to four months, to become fully effective.

Regarding CRP (C-reactive protein) of 26, this indicates active inflammation. As treatment begins to work, CRP should gradually decrease. Now, about warning signs of a flare. You should watch for the following signs and symptoms:

Increased abdominal pain, especially in the right lower abdomen.
Persistent or worsening diarrhea.
Blood or mucus in stool.
Fever.
Weight loss.
Mouth ulcers.
Joint pain.
Loss of appetite.

If he developed these symptoms, it indicates obstruction and needs urgent evaluation. Because his disease involves the terminal ileum, vitamin B12 deficiency is common. The terminal ileum is the main site where B12 is absorbed.

In patients with ileal Crohn’s disease, B12 injections are often necessary, especially if levels are significantly low. Weekly injections initially and then monthly.

Regarding diet, there is no single universal Crohn’s diet, but certain principles help, like a low-residue or low-fiber diet (to reduce irritation), avoiding raw vegetables, nuts, seeds, popcorn, avoiding very spicy, fatty, or processed foods, small, frequent meals, and a balanced diet with adequate protein.

CBC (complete blood count) and liver function tests every one to two weeks for the first month, then every four weeks for the next two to three months, once stable, every three months.

Common side effects of Azathioprine are nausea, mild hair thinning, and increased infection risk. Long-term use slightly increases the risk of certain cancers, but for many patients, the benefit of preventing uncontrolled Crohn’s disease outweighs this risk.

I hope this helps.

Thank you.