What are the treatment options for Inflammatory Bowel Disease (IBD)?

Treatment Options for Inflammatory Bowel Disease (IBD)

The treatment of inflammatory bowel disease requires a structured approach based on disease type (Crohn's disease or ulcerative colitis), location, severity, and pattern, with options ranging from aminosalicylates to biologics and surgery when appropriate. 1

Medical Management of Ulcerative Colitis (UC)

Mild to Moderate UC

• Active distal colitis should be treated with topical mesalazine or topical steroid combined with oral mesalazine to provide prompt symptom relief 1
• High-dose mesalazine (4 g/day) is effective for mild disease and represents first-line therapy due to its favorable safety profile 2
• Maintenance therapy is generally recommended lifelong for all patients, especially those with left-sided or extensive disease, to reduce relapse risk and potentially reduce colorectal cancer risk 1

Severe UC

• Patients failing maximal oral treatment or presenting with severe disease should be admitted for intensive intravenous therapy 1
• Management requires:
  • Daily physical examination to evaluate abdominal tenderness 1
  • Joint medical and surgical management 1
  • Regular monitoring of vital signs, stool frequency, inflammatory markers, and abdominal imaging 1
  • Intravenous fluid replacement and blood transfusion to maintain hemoglobin >10 g/dl 1
  • Subcutaneous heparin to reduce thromboembolism risk 1
  • Nutritional support if malnourished 1

Medical Management of Crohn's Disease (CD)

Active Disease

• For mild ileocolonic CD, high-dose mesalazine (4 g/day) may be sufficient initial therapy, though its efficacy is modest compared to its use in UC 1, 3
• For moderate to severe disease:
  • Corticosteroids are effective for inducing remission but have significant adverse effects 2
  • Budesonide may offer a better safety profile than conventional steroids 2
  • Immunomodulators (azathioprine 1.5-2.5 mg/kg/day or mercaptopurine 0.75-1.25 mg/kg/day) are first-line agents for steroid-dependent disease 1
  • Methotrexate (25 mg weekly IM for up to 16 weeks, then 15 mg weekly) is effective for chronic active disease 1
  • Infliximab (5 mg/kg) should be reserved for patients with moderate to severe CD who are refractory to or intolerant of other treatments 1

Biologic Therapies

• Tumor necrosis factor (TNF) blockers like adalimumab are indicated for:
  • Moderately to severely active Crohn's disease in adults and pediatric patients 6 years and older 4
  • Moderately to severely active ulcerative colitis in adults and pediatric patients 5 years and older 4
• Dosing for adalimumab in CD (adults):
  • 160 mg on Day 1 (given in one day or split over two consecutive days)
  • 80 mg on Day 15
  • 40 mg every other week starting on Day 29 4

Monitoring and Safety Considerations

• When using azathioprine or mercaptopurine:
  • Monitor full blood count within 4 weeks of starting therapy and every 6-12 weeks thereafter to detect neutropenia 1
  • Consider thiopurine methyltransferase activity testing before treatment 1
• Mesalazine (5-ASA) is generally well-tolerated but requires renal function monitoring before and during treatment due to rare nephrotoxic events 2
• Corticosteroids carry numerous adverse events including opportunistic infections, diabetes mellitus, hypertension, ocular effects, psychiatric complications, and increased fracture risk 2

Surgical Management

• For UC, surgery should be considered for:
  • Disease not responding to intensive medical therapy
  • Patients with dysplasia or carcinoma
  • Poorly controlled disease or recurrent acute episodes 1
• For CD, surgery should only be undertaken for:
  • Symptomatic rather than asymptomatic disease
  • Complications or refractory disease 5
  • Resections should be limited to macroscopic disease 1

Key Surgical Principles

• Patients requiring surgery are best managed under joint care of a surgeon and gastroenterologist 1
• Preoperative counseling and stoma site marking by a clinical colorectal nurse specialist 1
• For acute fulminant UC or CD, subtotal colectomy is the procedure of choice 1
• Primary anastomosis should be avoided in the presence of sepsis and malnutrition 1

Pain Management

• Identify and treat the underlying cause of pain (inflammation, obstruction, etc.) 1
• For non-specific pain relief, consider opioids with less effect on motility, such as tramadol 1

Treatment Approach Algorithm

1. Assess disease type, location, severity, and pattern 1
2. For mild-moderate UC: Start with aminosalicylates (oral and/or topical) 1
3. For moderate-severe UC: Consider corticosteroids, then immunomodulators if steroid-dependent 1
4. For severe UC: Hospitalize for intensive therapy; consider early surgical consultation 1
5. For mild CD: Consider high-dose mesalazine, though benefits may be modest 3
6. For moderate-severe CD: Consider corticosteroids for induction, immunomodulators for maintenance 1
7. For refractory disease: Consider biologics (TNF inhibitors) before considering surgery 4
8. Maintain remission with appropriate maintenance therapy based on disease type and previous treatment response 1

Common Pitfalls and Caveats

• Avoid prolonged corticosteroid use due to significant adverse effects; aim for corticosteroid-free remission 2
• Don't delay appropriate escalation of therapy in patients with severe or progressive disease 1
• Regular monitoring is essential when using immunomodulators to detect potential serious adverse effects 1
• Surgery should not be considered a "last resort" but an appropriate option in specific circumstances, particularly for UC where it can be curative 5
• Remember that CD is potentially panenteric and usually recurs following surgery, so conservative resections are preferred 1