What are the treatment options for Inflammatory Bowel Disease (IBD)?

Treatment Options for Inflammatory Bowel Disease (IBD)

The treatment of Inflammatory Bowel Disease requires a stepwise approach based on disease severity, location, and pattern, with aminosalicylates, corticosteroids, immunomodulators, biologics, and surgery forming the core therapeutic options. 1

Disease Classification and Initial Assessment

IBD is classified into two main types:

• Ulcerative colitis (UC): Affects the colon and rectum
• Crohn's disease (CD): Can affect any part of the gastrointestinal tract

Treatment decisions should consider:

• Disease location (ileal, ileocolonic, colonic, other)
• Disease pattern (inflammatory, stricturing, fistulating)
• Disease activity (mild, moderate, severe)

Medical Management of Ulcerative Colitis

Mild to Moderate Disease

• First-line therapy: High-dose mesalazine (5-ASA) at 4g/day 1, 2
  • Doses above 2.4g/day achieve higher rates of clinical and endoscopic remission
  • Monitor renal function before and during treatment due to rare nephrotoxicity 3

Moderate to Severe Disease

1. Oral corticosteroids: Prednisolone 40mg daily 1

   • Taper gradually over 8 weeks
   • Rapid reduction associated with early relapse

2. Severe disease requiring hospitalization:

   • Intravenous steroids (hydrocortisone 400mg/day or methylprednisolone 60mg/day)
   • Daily monitoring of vital signs, stool frequency, and abdominal examination
   • Regular laboratory tests (CBC, CRP, electrolytes, albumin)
   • Subcutaneous heparin for thromboembolism prophylaxis
   • Joint management with colorectal surgeon

Maintenance Therapy

• Lifelong maintenance therapy recommended for all patients, especially those with left-sided or extensive disease 1
• Options include:
  • Aminosalicylates
  • Azathioprine (1.5-2.5mg/kg/day) or mercaptopurine (0.75-1.25mg/kg/day)
  • Regular monitoring of blood counts required

Medical Management of Crohn's Disease

Mild Disease

• High-dose mesalazine (4g/day) may be sufficient for mild ileocolonic CD 1

Moderate to Severe Disease

1. Corticosteroids:

   • Prednisolone 40mg daily for moderate to severe disease
   • Budesonide 9mg daily for isolated ileo-cecal disease (fewer systemic side effects)

2. Immunomodulators for steroid-dependent or refractory disease:

   • Azathioprine (1.5-2.5mg/kg/day) or mercaptopurine (0.75-1.25mg/kg/day) 1, 4
   • Monitor CBC within 4 weeks of starting therapy and every 6-12 weeks thereafter
   • Methotrexate IM 25mg weekly for 16 weeks, then 15mg weekly 1

3. Biologics:

   • Infliximab (5mg/kg) for moderate to severe CD refractory to other treatments 1
   • Adalimumab for moderately to severely active CD in adults and pediatric patients 6 years and older 5

Maintenance Therapy

• Immunomodulation with azathioprine, mercaptopurine, or methotrexate if steroids cannot be withdrawn without disease flare 1
• Smoking cessation should be strongly encouraged for all CD patients 1

Surgical Management

Ulcerative Colitis

• Surgery indicated for disease not responding to intensive medical therapy, dysplasia/carcinoma, or poorly controlled disease 1
• Options include subtotal colectomy and ileo-anal pouch procedures

Crohn's Disease

• Surgery only for symptomatic disease, not asymptomatic radiologically identified disease 1
• Conservative resections limited to macroscopic disease
• Avoid primary anastomosis in the presence of sepsis and malnutrition

Special Considerations

Pain Management

• Identify and treat the underlying cause where possible
• Non-specific pain relief with agents having less effect on motility (e.g., tramadol) 1

Monitoring and Surveillance

• Regular monitoring of disease activity
• Colonoscopic surveillance for colorectal cancer in long-standing colitis

Digital Health Applications

• Web-based platforms like Constant Care can help with medication management and symptom monitoring 1
• Can potentially individualize treatment timing for biologics

Important Caveats

1. Medication Safety:

   • Corticosteroids: Limited by high incidence of adverse events including opportunistic infections, diabetes, hypertension, and increased fracture risk 3
   • Thiopurines: Risk of myelosuppression, hepatotoxicity, and potential increased risk of lymphoma 4
   • Regular laboratory monitoring essential for patients on immunosuppressive therapy

2. Treatment Goals:

   • Induce and maintain remission
   • Reduce mortality and morbidity
   • Improve quality of life
   • Corticosteroid-free remission should be a primary goal 3

3. Multidisciplinary Approach:

   • Joint care by gastroenterologist and colorectal surgeon for patients requiring surgery 1
   • Preoperative counseling and stoma site marking by clinical nurse specialists

The management of IBD has evolved significantly with new therapeutic targets, but the stepwise approach starting with conventional therapies and escalating based on response remains the cornerstone of treatment.