What is the guideline for treatment (GTT) of Crohn's disease and Ulcerative Colitis (UC)?

Guidelines for Treatment of Crohn's Disease and Ulcerative Colitis

For inflammatory bowel disease (IBD) treatment, a stepwise approach based on disease severity, location, and pattern is recommended, with aminosalicylates as first-line for UC and corticosteroids or biologics for CD, followed by immunomodulators or advanced therapies for refractory disease. 1

Ulcerative Colitis Treatment

First-Line Therapy

• Mild to Moderate Disease:
  • First-line: 5-ASA compounds (mesalazine 2-4g daily or balsalazide 6.75g daily) 1
  • For distal UC: Combination of topical mesalazine 1g daily plus oral mesalazine 2-4g daily 1
  • For extensive UC: Oral mesalazine 2-4g daily or balsalazide 6.75g daily 1

Second-Line Therapy

• If no response to 5-ASA within 2-4 weeks, add oral prednisolone 40mg daily 1
• Prednisolone should be reduced gradually over 8 weeks; rapid reduction leads to early relapse 2

Severe UC Management

• Joint management by gastroenterologist and colorectal surgeon 2
• Intravenous steroids (hydrocortisone 400mg/day or methylprednisolone 60mg/day) 2, 1
• Daily monitoring including:
  • Physical examination for abdominal tenderness
  • Vital signs four times daily
  • Stool chart recording
  • Laboratory tests every 24-48 hours
  • Abdominal radiography if colonic dilatation present 2
• Supportive care:
  • IV fluid and electrolyte replacement
  • Subcutaneous heparin for thromboembolism prophylaxis
  • Nutritional support if malnourished
  • Blood transfusion to maintain hemoglobin >10 g/dl 2

Maintenance Therapy

• Lifelong maintenance therapy recommended, especially for left-sided or extensive disease 2
• Options include:
  • Aminosalicylates (≥2g/day) 2, 1
  • Azathioprine (1.5-2.5mg/kg/day) or mercaptopurine (0.75-1.5mg/kg/day) for frequent relapsers 1

Crohn's Disease Treatment

Active Disease Management

• Mild Ileocolonic Disease:

  • High-dose mesalazine (4g/daily) 2, 1

• Moderate to Severe Disease:

  • Oral corticosteroids (prednisolone 40mg daily) 2
  • Budesonide 9mg daily for isolated ileo-cecal disease 2, 1
  • Intravenous steroids for severe disease with concomitant IV metronidazole 2

• Alternative Approaches:

  • Elemental or polymeric diets for patients with contraindications to corticosteroids 2
  • Metronidazole (10-20mg/kg/day) for active colonic disease 2
  • Antibiotics: metronidazole 400mg three times daily and/or ciprofloxacin 500mg twice daily 1

Maintenance Therapy

• Options include:
  • Azathioprine or mercaptopurine for steroid-dependent disease 2, 1
  • Methotrexate (15-25mg weekly) for patients who responded to initial methotrexate therapy 1

Advanced Therapies for Refractory IBD

• Biological Agents:

  • Anti-TNF agents (e.g., adalimumab): For moderately to severely active CD and UC 3
    • CD dosing: 160mg on Day 1, 80mg on Day 15, then 40mg every other week starting Day 29 3
    • UC dosing: 160mg on Day 1, 80mg on Day 15, then 40mg every other week starting Day 29 3
  • Anti-integrin agents
  • IL-12/23 inhibitors
  • JAK inhibitors
  • S1P receptor modulators 1

• Combination therapy with immunomodulators increases effectiveness of anti-TNF agents 1

Important Considerations

Treatment Outcomes

• Corticosteroids provide impressive short-term results but are not suitable for long-term management due to side effects 4
• One-year outcomes after corticosteroid treatment:
  • CD: 32% prolonged response, 28% steroid dependence, 38% requiring surgery 5
  • UC: 49% prolonged response, 22% steroid dependence, 29% requiring surgery 5

Treatment Goals

• Short-term: Symptom reduction and prevention of complications
• Long-term: Sustained clinical steroid-free remission and mucosal healing 6
• Treatment goals have shifted from clinical response to achieving biochemical, endoscopic, and histological remission 1

Monitoring and Supportive Care

• Keep patients informed of treatment and prognosis (25-30% chance of colectomy in severe UC) 2
• Smoking cessation is crucial for maintaining remission 1
• Patient support groups can provide educational materials and medication assistance 1

Treatment Algorithm for Severe Flares

1. Rule out complications (infections, strictures, abscesses, toxic megacolon)
2. Start IV steroid therapy
3. Assess response within 72 hours
4. If no improvement, intensify therapy with biologics or consider surgical options 6

Remember that corticosteroids should never be used for long-term maintenance due to side effects, and surgical options must always be considered as part of interdisciplinary care 1, 6.