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

Treatment Options for Inflammatory Bowel Disease (IBD)

The treatment of IBD should follow a stepwise approach, starting with aminosalicylates for mild to moderate disease, progressing to immunomodulators for steroid-dependent disease, and considering biologics like infliximab for refractory cases, with surgery reserved for specific indications when medical management fails. 1

Medical Management Based on Disease Type and Severity

Ulcerative Colitis (UC)

Mild to Moderate Disease

• First-line therapy: Combination of topical mesalazine 1g daily plus oral mesalamine 2-4g daily 2
  • High-dose mesalazine (4g/day) shows good efficacy 1
  • For distal disease: Topical mesalazine or topical steroid combined with oral mesalazine 1
  • Twice daily dosing improves compliance 1

Severe Disease

• Inpatient management required with:
  • IV corticosteroids (hydrocortisone 400 mg/day or methylprednisolone 60 mg/day) 2
  • Subcutaneous heparin for thromboembolism prophylaxis 1, 2
  • Daily monitoring of vital signs, stool frequency, and laboratory values 1
  • Joint management with colorectal surgeon 1

Crohn's Disease (CD)

Mild to Moderate Disease

• First-line: High-dose mesalazine (4g/day) may be sufficient for mild ileocolonic disease 1
• For moderate to severe disease: Corticosteroids, immunomodulators 1

Severe or Refractory Disease

• Immunomodulators: Azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.25 mg/kg/day) 1
• Methotrexate: 25mg weekly IM for 16 weeks, then 15mg weekly maintenance 1
• Biologics: Infliximab (5 mg/kg) for patients refractory to or intolerant of other treatments 1

Maintenance Therapy

• Lifelong maintenance therapy is generally recommended for all UC patients, especially those with left-sided or extensive disease 1, 2

• Options include:

  • Aminosalicylates (first-line for UC maintenance) 1, 3
  • Azathioprine or mercaptopurine (for steroid-dependent disease) 1
  • Methotrexate (alternative immunomodulator) 1

• Monitoring for immunomodulators:

  • FBC within 4 weeks of starting therapy and every 6-12 weeks thereafter 1
  • Consider TPMT testing before starting therapy (debated) 1

Surgical Management

Indications for Surgery

Ulcerative Colitis

• Disease not responding to intensive medical therapy 1
• Dysplasia or carcinoma 1
• Poorly controlled disease 1
• Toxic megacolon not responding to medical therapy within 24-48 hours 2

Crohn's Disease

• Only for symptomatic disease (not asymptomatic radiologically identified disease) 1
• Conservative resections limited to macroscopic disease 1
• Perforation, massive hemorrhage 2

Surgical Principles

• Joint care between surgeon and gastroenterologist 1
• Preoperative counseling and stoma site marking by a clinical colorectal nurse specialist 1
• For acute fulminant disease: Subtotal colectomy with long rectal stump 1
• Primary anastomosis should be avoided in sepsis and malnutrition 1

Monitoring and Follow-up

• Regular monitoring of disease activity through clinical assessment and laboratory tests 2
• Surveillance colonoscopy for colorectal cancer risk, especially in extensive UC 1, 2
• Digital health applications may help in monitoring symptoms and disease activity 1

Common Pitfalls to Avoid

1. Delaying corticosteroid treatment in acute UC while waiting for stool microbiology results 2
2. Failing to consider joint medical and surgical management for severe UC 2
3. Overlooking thromboembolism risk in severe UC patients 2
4. Neglecting maintenance therapy in UC patients, which increases colorectal cancer risk 2
5. Inadequate monitoring of patients on immunomodulators for bone marrow suppression 4

Pain Management

• Identify and treat the underlying cause when possible (corticosteroids for inflammation) 1, 2
• For non-specific pain relief, consider tramadol (less effect on motility than other opioids) 1, 2

Additional Considerations

• Nutritional support: Enteral or parenteral nutrition for malnourished patients 1
• Cancer prevention: Maintenance therapy with aminosalicylates may reduce colorectal cancer risk by up to 75% in UC patients 1, 5
• Emerging therapies: Small molecules, improved intestinal microecology, and cell therapy show promise for refractory cases 6

The treatment approach to IBD has evolved from targeting symptom relief to achieving mucosal healing, with a growing emphasis on early aggressive therapy to prevent complications and improve long-term outcomes 6.