Treatment of Inflammatory Bowel Disease
The recommended first-line treatment for inflammatory bowel disease depends on disease type, location, and severity, with aminosalicylates being the cornerstone therapy for mild to moderate ulcerative colitis and corticosteroids for more severe disease or Crohn's disease. 1, 2
Treatment Based on Disease Type
Ulcerative Colitis (UC)
Mild to Moderate Disease
Distal UC (Proctitis/Left-sided):
- First-line: Combination of topical mesalazine 1g daily plus oral mesalazine 2-4g daily 1
- Topical corticosteroids are less effective than topical mesalazine and should be reserved as second-line therapy for patients intolerant to topical mesalazine 1
- Proximal constipation should be treated with stool bulking agents or laxatives 1
Extensive UC:
Moderate to Severe Disease
- Oral prednisolone 40mg daily for patients requiring prompt response or those who failed mesalazine therapy 1, 2
- Gradual taper over 8 weeks to minimize risk of early relapse 1
Severe UC Requiring Hospitalization
- Intravenous steroids (hydrocortisone 400mg/day or methylprednisolone 60mg/day) 1, 2
- Intravenous fluid and electrolyte replacement 1
- Subcutaneous heparin for thromboembolism prophylaxis 1
- Blood transfusion to maintain hemoglobin >10 g/dl 1
- Nutritional support if malnourished 1
Crohn's Disease (CD)
Mild Disease
- Ileal/Ileocolonic: High-dose mesalazine (4g daily) may be sufficient 1, 2
- Colonic: Sulphasalazine 4g daily is effective but has higher side effect profile 1
Moderate to Severe Disease
- Oral corticosteroids: Prednisolone 40mg daily with gradual taper over 8 weeks 1
- Isolated ileo-cecal disease: Budesonide 9mg daily (less systemic effects than prednisolone) 1, 2
- Severe disease: Intravenous steroids (hydrocortisone 400mg/day or methylprednisolone 60mg/day) 1
Fistulating/Perianal Disease
- First-line: Metronidazole 400mg three times daily and/or ciprofloxacin 500mg twice daily 1
- Second-line: Azathioprine 1.5-2.5mg/kg/day or mercaptopurine 0.75-1.5mg/kg/day 1
- Refractory cases: Infliximab 5mg/kg at weeks 0,2, and 6 1, 3
- Surgical intervention (Seton drainage, fistulectomy) in combination with medical therapy for complex fistulae 1
Maintenance Therapy
Ulcerative Colitis
- Lifelong maintenance therapy generally recommended, especially for extensive disease 1
- Mesalazine 2-4g daily (ineffective at doses <2g/day) 1, 2
Crohn's Disease
- Smoking cessation is crucial for maintaining remission 1
- Azathioprine 1.5-2.5mg/kg/day or mercaptopurine 0.75-1.5mg/kg/day for patients who relapse more than once per year 1, 2
- Methotrexate (15-25mg weekly) for patients who responded to initial methotrexate therapy 1
- Infliximab 5-10mg/kg every 8 weeks for maintenance in patients who responded to initial infusion 1, 3
Important Considerations and Pitfalls
Corticosteroid dependence: Long-term steroid use is undesirable. Patients with chronic active steroid-dependent disease should be treated with azathioprine or mercaptopurine 1, 4
Aminosalicylate side effects: While generally well-tolerated, rare cases of nephrotoxicity have been reported. Monitor renal function before and during treatment 4, 5
Steroid side effects: Include opportunistic infections, diabetes mellitus, hypertension, ocular effects, psychiatric complications, and increased fracture risk 4
Medication adherence: Non-adherence to mesalazine is common and can lead to treatment failure 6
Pregnancy considerations: Mesalazine is considered safe in pregnancy, excluding formulations with dibutyl phthalate 6
Treatment escalation: When initial therapy fails, promptly escalate to more potent options rather than persisting with ineffective treatments 1, 2
By following this treatment algorithm based on disease type, location, and severity, most patients with inflammatory bowel disease can achieve remission and maintain improved quality of life.