Inflammatory Bowel Disease: Treatement

The goal of treatment is to reduce the inflammation that triggers signs and symptoms and to induce remission. Treatment involves medication in mild to moderate cases, or surgery in severe and refractory cases. The following medications are commonly prescribed for patients with IBD:

Aminosalicylates. Sulfasalazine can be administered orally, in enema formulations, or as suppositories. However, it has numerous common side effects, which include infertility in men. Oral mesalamine has significantly fewer side effects for people who cannot tolerate sulfasalazine.

Corticosteroids. Prednisone, methylprednisolone, and hydrocortisone control inflammation in moderate–to–severe cases of IBD, but they all have numerous short–term and long–term side effects. Budesonide, however, is designed to be released specifically in the ileum and ascending colon, where Crohn's is most active. It is effective, and is rapidly metabolized and quickly cleared from the blood with relatively few side effects.

Broad–spectrum antibiotics. Ciprofloxacin, metronidazole, and ampicillin can be used as first–line therapy when purulent perianal disease is present, but are adjunctive therapies in flares of colonic Crohn’s disease, in severe ulcerative colitis, in Crohn’s disease unresponsive to other medical therapy, and in patients with severe side effects from other medications. These agents alter the bacterial composition of the intestines and suppress the intestine’s immune system.² Ciprofloxacin is preferred to metronidazole, which causes peripheral neuropathy when used chronically.

Immunomodulators. Azathioprine and mercaptopurine reduce the steroid dosage needed, aid in healing fistulas, and help maintain disease remission. Cyclosporine A is used in acute flares of ulcerative colitis resistant to other medications. These drugs have greater toxicity than corticosteroids and may cause kidney damage, hepatitis, hypertension, seizures, immunosuppression, and increased risk of lymphoma.

Biologic therapy (proteins, genes, and antibodies). These agents are used in patients who have not responded to conventional therapy. Infliximab is a chimeric monoclonal antibody that blocks the immune system's production of tumor necrosis factor–α. Adalizumab appears to have efficacy similar to that of infliximab.

Symptomatic Treatment

The following treatments may be used for symptomatic relief:

Antidiarrheals, such as loperamide, may be effective.

Increased fiber intake should be encouraged when constipation occurs.

Iron supplements are used when chronic intestinal bleeding leads to iron–deficient anemia. When anemia is the result of chronic inflammation, erythropoietin may be required, in addition to iron supplements.

Vitamin B₁₂ injections, high–dose oral administrations, or nasal sprays are needed in cases in which persistent diarrhea causes inadequate B₁₂ absorption, or when the terminal ileum is affected in Crohn’s disease. The vitamin also promotes normal growth and development in children.

Surgery

Total colectomy may be necessary in severe cases of ulcerative colitis. Bowel resection is indicated in Crohn’s disease when severe complications occur, including bleeding, strictures, and fistulas.

However, surgery is not usually curative. Postsurgery relapses can be reduced by continuous preventive treatment with 6–mercaptopurine or azathioprine, and possibly with aminosalicylates or metronidazole.

Lifestyle Factors

Psychological factors should be addressed. Studies suggest a role for psychologic stress in exacerbations of ulcerative colitis and a role for depression in Crohn’s disease.³ A number of psychosocial factors (eg, gender, socioeconomic status, and ethnicity) appear to impact IBD.⁴ Limited evidence indicates that stress reduction reduces symptoms in patients with Crohn’s disease, when compared with a control group treated conventionally,⁵ and results in less pain and decreased need for anti–inflammatory medication in patients with ulcerative colitis.⁶ However, clinical trials of such interventions are hampered by placebo effects and difficulties in securing a blind design.⁷ Additional studies are required.

Exercise. IBD patients can benefit from exercise. Although only limited evidence suggests that exercise reduces risk for the onset of IBD, benefits of regular activity include improvement of psychological symptoms; improvements in muscle strength and bone health, which are often impaired with glucocorticoid therapy; and a reduced risk for colon cancer that may result from long–standing IBD.⁸