What is the treatment approach for inflammatory bowel disease?

Treatment Approach for Inflammatory Bowel Disease

The treatment of inflammatory bowel disease requires a disease-specific approach based on location, severity, and pattern of disease, with aminosalicylates as first-line therapy for ulcerative colitis and corticosteroids, immunomodulators, or biologics for Crohn's disease. 1

Ulcerative Colitis Treatment

Mild to Moderate Disease

• For distal disease (proctitis/left-sided colitis):

  • First-line: Combination of topical mesalazine 1g daily + oral mesalazine 2-4g daily
  • Topical mesalazine is more effective than topical corticosteroids
  • Combination therapy is more effective than either agent alone 1
  • Proximal constipation should be treated with stool bulking agents

• For extensive disease:

  • Oral mesalazine 2-4g daily or equivalent (olsalazine 1.5-3g daily or balsalazide 6.75g daily)
  • Sulphasalazine 2-4g daily is effective but has more side effects than newer 5-ASA drugs 1

Treatment Failure or Moderate to Severe Disease

• Oral prednisolone 40mg daily if no response to mesalazine therapy
• Taper prednisolone gradually over 8 weeks based on response 1
• Long-term steroid use should be avoided due to side effects 2

Severe Disease

• Hospitalization for intensive intravenous therapy
• Joint management with colorectal surgeon (25-30% may need colectomy)
• Daily monitoring of vital signs, stool frequency, and laboratory parameters
• Subcutaneous heparin for thromboembolism prevention
• Nutritional support if malnourished 1

Crohn's Disease Treatment

Active Disease

• Treatment approach depends on disease location (ileal, ileocolonic, colonic) and pattern (inflammatory, stricturing, fistulating)
• First-line options include:
  • Corticosteroids for moderate to severe disease
  • Immunomodulators (azathioprine 1.5-2.5 mg/kg/day or mercaptopurine 0.75-1.5 mg/kg/day) for steroid-dependent disease 1
  • Infliximab (5 mg/kg at 0,2, and 6 weeks, then every 8 weeks) for moderate to severe disease that has failed conventional therapy 3

Fistulizing Disease

• Metronidazole 400mg three times daily and/or ciprofloxacin 500mg twice daily for simple perianal fistulae
• Azathioprine/mercaptopurine for simple perianal or enterocutaneous fistulae
• Infliximab for refractory fistulae, used as part of a strategy including immunomodulation and surgery 1
• Surgical approaches (seton drainage, fistulectomy) for persistent or complex fistulae 1

Maintenance Therapy

Ulcerative Colitis

• Lifelong maintenance therapy recommended, especially for:
  • Left-sided or extensive disease
  • Distal disease with >1 relapse per year
  • Maintenance therapy may reduce colorectal cancer risk 1
• Options include aminosalicylates, azathioprine, or mercaptopurine 1

Crohn's Disease

• Smoking cessation is crucial (strongest recommendation)
• Azathioprine 1.5-2.5 mg/kg/day or mercaptopurine 0.75-1.5 mg/kg/day for frequent relapses
• Methotrexate (15-25 mg IM weekly) for those who responded to IM methotrexate or failed azathioprine/mercaptopurine
• Infliximab (5-10 mg/kg every 8 weeks) for maintenance in responders 1
• Corticosteroids are not effective for maintenance therapy 1

Monitoring and Safety Considerations

• For aminosalicylates:

  • Monitor renal function before and during therapy
  • Rare side effects include nephritis, pulmonitis, hepatitis 2, 4
  • Higher doses (4.8g vs 2.4g daily) may be more effective 5

• For immunomodulators:

  • Monitor for bone marrow suppression, hepatitis, and opportunistic infections 2
  • Methotrexate is contraindicated in pregnancy 2

• For biologics (infliximab):

  • Screen for tuberculosis before starting therapy
  • Monitor for serious infections and malignancy
  • Discontinue if serious infection develops 3

Common Pitfalls to Avoid

1. Delaying treatment with corticosteroids in severe UC while waiting for stool microbiology results 1
2. Prolonged steroid use instead of introducing steroid-sparing agents 1
3. Inadequate dosing of mesalazine (doses <2g/day are less effective) 1, 5
4. Failing to consider surgery in appropriate cases of severe disease 1
5. Not monitoring renal function in patients on aminosalicylates 4
6. Overlooking the importance of smoking cessation in Crohn's disease 1
7. Not providing prophylaxis against thromboembolism in hospitalized patients with severe disease 1

By following these evidence-based treatment approaches and monitoring protocols, most patients with IBD can achieve disease control and maintain remission, improving their quality of life and reducing complications.