What are the treatment options for Inflammatory Bowel Disease (IBD) using Gastrointestinal Medications And Therapies (GIMATS)?

Treatment Options for Inflammatory Bowel Disease (IBD) Using Gastrointestinal Medications And Therapies (GIMATS)

The comprehensive management of IBD requires a stepwise approach using various gastrointestinal medications and therapies, with immunomodulators, biologics, and aminosalicylates forming the cornerstone of treatment for both Crohn's disease and ulcerative colitis. 1

First-Line Therapies

• Aminosalicylates (5-ASA): Effective for mild to moderate ulcerative colitis, particularly for inducing and maintaining remission. Less effective in Crohn's disease. Available as oral and rectal formulations (suppositories, enemas) for distal disease. 1

• Corticosteroids: Prednisolone 40mg daily is appropriate for patients requiring prompt response or those with mild to moderately active disease unresponsive to mesalazine. Should be tapered gradually over 8 weeks to avoid early relapse. Not suitable for long-term use due to side effects. 1

• Antibiotics: Rifaximin has shown benefit in Crohn's disease and steroid-refractory ulcerative colitis, though its exact mechanism in IBD remains unclear. 1

Second-Line Therapies

• Immunomodulators: Should be tried when steroids cannot be withdrawn without disease deterioration. 1

  • Azathioprine (1.5-2.5 mg/kg/day) or Mercaptopurine (0.75-1.5 mg/kg/day): Effective for chronic active steroid-dependent disease. Regular monitoring of full blood count is advisable to detect neutropenia. 1
  • Methotrexate: 25mg IM weekly for up to 16 weeks followed by 15mg weekly is effective for chronic active Crohn's disease. Oral dosing is effective for many patients. 1

• Biologics:

  • Infliximab (5 mg/kg): Reserved for moderate to severe Crohn's disease refractory to or intolerant of steroids, mesalazine, azathioprine/mercaptopurine, and methotrexate, when surgery is inappropriate. Standard dosing is at 0,2, and 6 weeks, then every 8 weeks. 1, 2
  • Other TNF inhibitors (adalimumab, golimumab, certolizumab) 1
  • Ustekinumab: IL-12/23 inhibitor effective for Crohn's disease 1
  • Vedolizumab: Gut-selective anti-integrin agent 1
  • JAK inhibitors (tofacitinib): Oral small molecule therapy 1

Management of Specific Symptoms

For Diarrhea

• Loperamide: Effective for diarrhea control in Crohn's disease. 1, 3
• Bile acid sequestrants: Effective for diarrhea in Crohn's disease with malabsorption. 1, 3

For Constipation

• Polyethylene glycol (PEG): Safe and effective for constipation in IBD. 1
• Stimulant laxatives: Generally safe in IBD. 1
• Secretagogues and prokinetics: 5-HT receptor agonists effective for chronic constipation. 1

For Pain Management

• Antispasmodics: Consider for functional pain in IBD. 1
• Tricyclic antidepressants: Associated with benefit in IBD and effective for IBS-related pain. 1
• Tramadol: May help with non-specific pain relief with less effect on motility than other opioids. 1

Adjunctive Therapies

• Dietary Interventions: Low FODMAP diet shows evidence of benefit in Crohn's disease. 1

• Psychological Therapies: Cognitive behavioral therapy, hypnotherapy, and mindfulness therapy show efficacy for abdominal symptoms and are clinically valuable options in IBD. 1

• Probiotics: While showing variable success, they have low risk of harm. Further research needed for functional symptoms in IBD. 1

• Physical Exercise: Beneficial in quiescent or mild IBD, associated with decreased risk of active disease among Crohn's disease patients in remission. 1

• Pelvic Floor Therapy: Biofeedback shows benefit in 30% of IBD patients in remission with defecatory disorders. 1

Surgical Considerations

• Surgery should be advised for ulcerative colitis not responding to intensive medical therapy, with decisions best made jointly by gastroenterologist and colorectal surgeon in consultation with the patient. 1

• For Crohn's disease, surgery should only be undertaken for symptomatic rather than asymptomatic disease, as it is potentially panenteric and usually recurs following surgery. Resections should be conservative and limited to macroscopic disease. 1

Treatment Algorithm

1. Assess disease severity and location:

   • Mild to moderate disease: Start with aminosalicylates (for UC) or antibiotics/budesonide (for CD) 1
   • Moderate to severe disease: Consider early introduction of immunomodulators or biologics 1

2. If inadequate response to first-line therapy:

   • Add corticosteroids for acute flares (prednisolone 40mg daily) 1
   • Begin immunomodulators if steroid-dependent 1

3. For refractory disease:

   • Introduce biologics (infliximab, adalimumab, etc.) 1, 2
   • Consider combination therapy with immunomodulator and biologic for selected patients 1

4. For symptom management:

   • Diarrhea: Loperamide, bile acid sequestrants 1, 3
   • Pain: Antispasmodics, tricyclic antidepressants 1
   • Constipation: PEG, stimulant laxatives 1

5. Consider surgery when medical therapy fails, particularly for ulcerative colitis or localized Crohn's disease with complications 1

Common Pitfalls and Caveats

• Long-term steroid use: Avoid prolonged steroid therapy due to significant side effects. If patients cannot be weaned off steroids, initiate immunomodulators. 1

• Monitoring for immunomodulator toxicity: Regular blood count monitoring is essential with azathioprine/mercaptopurine to detect neutropenia, though there is debate about routine TPMT testing. 1

• Biologic therapy risks: Infliximab and other biologics carry risks of serious infections and malignancies. Screening for tuberculosis is essential before starting therapy. 2

• Symptom vs. inflammation discrepancy: Functional GI symptoms may persist despite controlled inflammation. Proper diagnostic evaluation is needed to differentiate between active IBD and functional symptoms. 1