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 Treatment Options

First-Line Therapies

• Aminosalicylates (5-ASA):

  • First-line for mild to moderate ulcerative colitis
  • Well-tolerated with safety profile comparable to placebo 2
  • Rare side effects include nephrotoxicity; monitoring of renal function recommended 2
  • Various formulations available with simplified dosing schedules to improve adherence 3

• Corticosteroids:

  • Effective for inducing remission in both UC and Crohn's disease 1
  • IV corticosteroids (hydrocortisone 400 mg/day or methylprednisolone 60 mg/day) for severe disease 1
  • Significant adverse effects include opportunistic infections, diabetes, hypertension, glaucoma, psychiatric complications, and increased fracture risk 2
  • Budesonide (rapidly metabolized steroid) has fewer systemic side effects 2
  • Should be weaned off ideally 4 weeks before surgery if surgical intervention is planned 1

Second-Line Therapies

• Immunomodulators:
  • For steroid-dependent disease or maintenance therapy
  • Options include azathioprine, mercaptopurine, and methotrexate
  • Require monitoring for bone marrow suppression, hepatitis, and opportunistic infections 4
  • Methotrexate is contraindicated in pregnancy 4
  • Should be stopped before surgery to decrease postoperative complications 1

Biologics

• TNF Inhibitors (e.g., Adalimumab/Humira):
  • Indicated for moderately to severely active Crohn's disease and ulcerative colitis 5
  • Dosing for Crohn's disease (adults): 160 mg on Day 1,80 mg on Day 15, then 40 mg every other week starting Day 29 5
  • Dosing for ulcerative colitis (adults): 160 mg on Day 1,80 mg on Day 15, then 40 mg every other week starting Day 29 5
  • Pediatric dosing available for both conditions based on weight 5
  • Serious risks include infections (including TB), malignancy (including lymphoma), and hepatosplenic T-cell lymphoma 5

Antibiotics

• Used in specific situations (superinfection, intra-abdominal abscesses, or sepsis) 1
• Generally safe and well-tolerated, though metronidazole carries risk of peripheral neuropathy with long-term use 4

Surgical Treatment Options

Indications for Surgery

1. Emergency Indications:

   • Toxic megacolon with perforation
   • Massive bleeding
   • Clinical deterioration or shock
   • Free perforation or generalized peritonitis
   • Life-threatening hemorrhage with persistent hemodynamic instability 1

2. Non-emergency Indications:

   • No clinical improvement after 24-48 hours of medical treatment
   • Significant recurrent gastrointestinal bleeding
   • Obstructive gastrointestinal luminal stenosis due to fibrotic scar tissue
   • Complicated fistula formation 1, 6

Surgical Procedures

• Subtotal colectomy with ileostomy: Treatment of choice for acute severe ulcerative colitis with massive hemorrhage 1
• Restorative proctocolectomy with ileal pouch-anal anastomosis: Common procedure for ulcerative colitis 6

Supportive Care

Thromboembolism Prophylaxis

• Subcutaneous heparin (LMWH) recommended for hospitalized patients 1
• Overlooking thromboembolism risk is a common pitfall 1

Nutritional Support

• Crucial for all IBD patients; neglecting it can lead to poor outcomes
• Enteral or parenteral nutrition recommended for malnourished patients 1

Disease Monitoring and Follow-up

Regular Assessment

• Clinical assessment and laboratory tests to monitor disease activity
• Surveillance colonoscopy for colorectal cancer risk, especially in extensive UC 1
• Complete colonoscopy at initial diagnosis, then every 5 years if no findings 1

Maintenance Therapy

• Lifelong maintenance therapy generally recommended for all UC patients
• Options include aminosalicylates, azathioprine or mercaptopurine, and methotrexate 1

Common Pitfalls to Avoid

• Delaying corticosteroid treatment while waiting for stool microbiology results
• Failing to consider joint medical and surgical management for severe UC
• Overlooking thromboembolism risk in severe UC patients
• Neglecting maintenance therapy, which may increase colorectal cancer risk
• Inadequate follow-up after colorectal cancer treatment 1

Treatment Algorithm

1. Mild to Moderate Disease:

   • Start with aminosalicylates (5-ASA)
   • If inadequate response, add oral corticosteroids

2. Moderate to Severe Disease:

   • Corticosteroids for induction of remission
   • Add immunomodulators for maintenance and steroid-sparing effect
   • Consider biologics if inadequate response

3. Severe/Fulminant Disease:

   • IV corticosteroids
   • VTE prophylaxis with LMWH
   • Multidisciplinary evaluation
   • If no improvement within 24-48 hours, consider surgical intervention

4. Maintenance Therapy:

   • Aminosalicylates for mild disease
   • Immunomodulators or biologics for more severe disease
   • Regular monitoring and surveillance

The goal of treatment has shifted from merely controlling symptoms to achieving mucosal healing, which is associated with better long-term outcomes including reduced hospitalization and surgery rates 7.