What is the management (mx) of Inflammatory Bowel Disease (IBD), including Crohn's disease (CD) and Ulcerative Colitis (UC)?

Management of Inflammatory Bowel Disease (IBD)

The management of IBD (Crohn's disease and ulcerative colitis) requires a stepwise approach with immunomodulators like azathioprine, mercaptopurine, or methotrexate as the cornerstone therapy when steroids cannot be withdrawn without disease deterioration. 1

Pharmacological Management

Ulcerative Colitis (UC)

Mild to Moderate UC

• First-line therapy: 5-aminosalicylates (5-ASA/mesalamine)
  • Oral: 2-4g daily 2
  • Rectal formulations for distal disease
  • High-dose therapy may be valuable for moderately active disease 3

Moderate to Severe UC

1. Acute Severe UC (ASUC):

   • IV corticosteroids: methylprednisolone 60 mg daily or hydrocortisone 100 mg four times daily 2
   • Continue for 7-10 days (longer courses offer no additional benefit) 2
   • Day 3 assessment is critical: poor response indicators include >8 stools/day or 3-8 stools/day with CRP >45 mg/L 2

2. Rescue therapy for steroid-refractory disease:

   • Infliximab or ciclosporin 2

3. Maintenance therapy:

   • Immunomodulators: azathioprine, mercaptopurine, or methotrexate 1, 4
   • Biologic agents:
     • TNF inhibitors: adalimumab, infliximab, golimumab 5, 6
     • Integrin inhibitors: vedolizumab 7, 6

Crohn's Disease (CD)

1. Induction therapy:

   • Corticosteroids for moderate-severe disease
   • Methotrexate IM 25 mg weekly for up to 16 weeks (Grade A evidence) 1
   • Oral methotrexate is effective for many patients (Grade B evidence) 1

2. Maintenance therapy:

   • Immunomodulators: azathioprine, mercaptopurine, or methotrexate 1
   • Methotrexate 15 mg weekly after induction 1

3. Biologic therapy:

   • Infliximab (5 mg/kg) for moderate to severe CD refractory to or intolerant of steroids, mesalazine, azathioprine/mercaptopurine, and methotrexate 1
   • Adalimumab for moderate to severe CD 5
   • Vedolizumab for moderate to severe CD 7

Surgical Management

Ulcerative Colitis

• Surgery indicated for:

  • Disease not responding to intensive medical therapy
  • Dysplasia or carcinoma
  • Poorly controlled disease
  • Recurrent acute on chronic episodes 1

• Procedure of choice in acute fulminant UC: subtotal colectomy leaving a long rectal stump 1

• Elective surgery options include ileo-anal pouch 1

Crohn's Disease

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

Supportive Care

1. Pain management:

   • Treat underlying cause when possible
   • Consider tramadol for non-specific pain relief (less effect on motility) 1
   • Avoid opioids, anticholinergics, and anti-diarrheals during flares 2

2. Thromboprophylaxis:

   • Low-molecular-weight heparin and compression stockings, especially during flares 2

3. Nutritional support:

   • Nutritional assessment and support as needed 2

4. Blood transfusion:

   • Maintain adequate hemoglobin levels 2

Surveillance for Complications

1. Colorectal cancer surveillance:

   • Colonoscopy after 8-10 years to re-evaluate disease extent (Grade C evidence) 1
   • Discuss with patients their individual risk and surveillance options 1

2. Medication monitoring:

   • For immunomodulators: FBC within 4 weeks of starting therapy and every 6-12 weeks thereafter 1
   • Test for C. difficile and other pathogens before starting immunosuppressive therapy 2

Multidisciplinary Approach

• Joint care by gastroenterologist and colorectal surgeon with interest in IBD (Grade C evidence) 1, 2
• Early surgical consultation for patients not improving within 48-72 hours of medical therapy 2
• Involvement of dietitians, IBD nurses, pharmacists, and stomal therapists 2
• Preoperative counseling and stoma site marking by clinical colorectal nurse specialist 1

Common Pitfalls and Caveats

1. Medication adherence:

   • Poor adherence to 5-ASA is common and leads to worse outcomes 8
   • Once-daily dosing may improve adherence 8

2. Treatment delays:

   • Prolonged ineffective steroid therapy can lead to unnecessary delays and increased risk of complications 2

3. Overlooked infections:

   • Missing C. difficile infection can lead to inadequate treatment and disease worsening 2

4. Thromboembolism risk:

   • Overlooking VTE prophylaxis increases risk of thrombotic events, especially during flares 2

5. Electrolyte management:

   • Inadequate potassium replacement can worsen colonic dilatation 2