What is the management approach for ulcerative colitis and Crohn's disease?

Management of Ulcerative Colitis and Crohn's Disease

The management of ulcerative colitis (UC) and Crohn's disease (CD) requires a step-up approach starting with oral mesalamine (5-ASA) for mild UC, oral corticosteroids for moderate disease, and progressing to biologics like infliximab or ustekinumab for severe or refractory disease, with surgery reserved for complications or treatment failures. 1

Diagnosis and Severity Assessment

• Severity Classification:

  • Severe UC: Bloody stool frequency ≥6/day plus one of: tachycardia (>90 bpm), temperature >37.8°C, anemia, or elevated inflammatory markers 1
  • Active Inflammation: Fecal calprotectin >150 mg/g indicates active disease 1

• Essential Diagnostic Tests:

  • Complete blood count
  • Inflammatory markers (CRP or ESR)
  • Electrolytes and liver function tests
  • Stool sample for culture and C. difficile toxin assay 1

Treatment Approach for Ulcerative Colitis

Mild to Moderate Disease

• First-line: Oral mesalamine 2-3g/day for induction and maintenance 1
• Topical Therapy: For distal disease, add topical mesalamine (suppositories or enemas) 1

Moderate to Severe Disease

• Oral corticosteroids: 40-60 mg daily with high-dose oral mesalamine (4 g/day) 1
• Steroid-dependent disease: Add azathioprine or mercaptopurine as steroid-sparing agents 1

Severe or Refractory Disease

• Rescue therapy: Infliximab or cyclosporine if no improvement within 3-5 days 1
• Biologic options:
  • Infliximab: 5 mg/kg at weeks 0,2, and 6, then every 8 weeks 1
  • Vedolizumab: For steroid-refractory cases 1
  • Ustekinumab: For moderately to severely active UC 2

Treatment Approach for Crohn's Disease

Mild to Moderate Disease

• First-line: Budesonide 9 mg daily (preferred over systemic steroids due to fewer side effects) 1
• Note: Mesalamine has limited benefit in small bowel CD 1

Moderate to Severe Disease

• Systemic corticosteroids: For induction of remission (60-83% effective) 1
• Immunomodulators:
  • Azathioprine/6-mercaptopurine for maintenance after steroid-induced remission 1
  • Methotrexate as an alternative immunomodulator 1

Severe or Refractory Disease

• Biologics:
  • Anti-TNF agents (infliximab, adalimumab) 1
  • Ustekinumab for moderately to severely active CD 2
  • Vedolizumab for moderate to severe CD 1, 3

Surgical Management

Indications for Surgery

• Disease not responding to intensive medical therapy
• Complications (strictures, fistulas)
• Dysplasia or carcinoma
• Poorly controlled disease 1

Emergency Surgery Indications

• Free perforation
• Massive hemorrhage
• Generalized peritonitis
• Toxic megacolon not responding to medical therapy
• Clinical deterioration despite appropriate medical management 1

Surgical Principles

• Joint care by surgeon and gastroenterologist
• For severe UC: subtotal colectomy with ileostomy
• For localized CD: consider segmental resection if appropriate
• Preserve maximum possible intestinal length
• Avoid primary anastomosis in presence of sepsis or malnutrition 1

Monitoring and Supportive Care

• Inpatient Monitoring: Daily vital signs, abdominal examination, stool frequency/character

• Laboratory Monitoring: CBC, CRP, electrolytes, albumin, liver function tests

• Supportive Care:

  • IV fluid resuscitation
  • Electrolyte monitoring and replacement
  • Venous thromboembolism prophylaxis
  • NPO status if severe symptoms or risk of perforation 1

• Response Assessment:

  • Clinical response within 3-7 days of initiating therapy
  • Endoscopic assessment after 4-8 weeks to confirm mucosal healing 1

Special Considerations

Medication Safety

• Ustekinumab warnings:
  • Posterior Reversible Encephalopathy Syndrome (PRES) risk
  • Serious allergic reactions
  • Lung inflammation
  • Avoid live vaccines 2

Infection Prevention

• Test for C. difficile and other pathogens before starting immunosuppressive therapy
• Treat C. difficile colitis with vancomycin 125mg orally four times daily 1

Pregnancy

• Most IBD medications are safe during pregnancy
• Active disease poses greater risk than treatment 1

Common Pitfalls to Avoid

• Overprescribing mesalamine for CD (limited efficacy)
• Inappropriate use of steroids for perianal CD or when sepsis is present
• Delayed introduction or underdosing of immunomodulators
• Missing C. difficile infection (always test before escalating therapy)
• Overlooking VTE prophylaxis in hospitalized patients
• Delaying surgical consultation when appropriate 1

Drug Interactions with Biologics

• Monitor patients on CYP450 substrates (e.g., warfarin, cyclosporine) when initiating ustekinumab
• Exercise caution in patients receiving allergen immunotherapy
• Safety of combining immunosuppressives with phototherapy not well established 2