What is the treatment for inflammatory bowel disease (IBD)?

Treatment of Inflammatory Bowel Disease

The treatment of inflammatory bowel disease requires a stepwise approach starting with first-line therapies like aminosalicylates for mild to moderate ulcerative colitis, advancing to corticosteroids, immunomodulators, and biologics for more severe or refractory disease, with the goal of achieving and maintaining remission while improving quality of life. 1

Diagnosis and Assessment

• A stepwise approach to rule out ongoing inflammatory activity should be followed in IBD patients with persistent GI symptoms using fecal calprotectin measurement, endoscopy with biopsy, and cross-sectional imaging 2
• Anatomic abnormalities or structural complications should be considered in patients with obstructive symptoms including abdominal distention, pain, nausea, vomiting, or constipation 2
• Alternative pathophysiologic mechanisms should be evaluated based on symptom patterns, including small intestinal bacterial overgrowth, bile acid diarrhea, and carbohydrate intolerance 2

First-Line Therapies

• Aminosalicylates (5-ASA compounds) are effective for mild to moderate ulcerative colitis for both inducing and maintaining remission, but have less effectiveness in Crohn's disease 1, 3
• Corticosteroids (such as prednisolone 40mg daily) are recommended for patients requiring prompt response or those with mild to moderately active disease unresponsive to mesalazine, and should be tapered gradually over 8 weeks 1, 4
• Antibiotics like rifaximin have shown benefit in Crohn's disease and steroid-refractory ulcerative colitis 1, 5

Second-Line Therapies

• Immunomodulators (azathioprine, mercaptopurine) are recommended for chronic active steroid-dependent disease, with regular monitoring of full blood count to detect neutropenia 1, 2
• Biologics, such as infliximab, are indicated for moderate to severe Crohn's disease refractory to or intolerant of steroids, mesalazine, and immunomodulators 1, 6
• Infliximab has demonstrated efficacy in both active Crohn's disease and fistulizing Crohn's disease, with significant improvement in clinical response, remission rates, and mucosal healing 6
• Other biologics including ustekinumab, vedolizumab, and JAK inhibitors like tofacitinib are recommended for treatment of IBD 1, 7

Management of Specific Symptoms

• For diarrhea control in Crohn's disease, hypomotility agents or bile-acid sequestrants may be used for chronic diarrhea in quiescent IBD 2, 1
• Osmotic and stimulant laxatives should be offered to IBD patients with chronic constipation 2
• Antispasmodics, neuropathic-directed agents, and anti-depressants should be used for functional pain in IBD, while opiates should be avoided 2, 1
• For IBD-associated arthropathy related to IBD activity, the mainstay of symptom relief should be through control of intestinal inflammation, physiotherapy, and simple analgesia 2

Adjunctive Therapies

• A low FODMAP diet may be offered for management of functional GI symptoms in IBD with careful attention to nutritional adequacy 2, 1
• Psychological therapies including cognitive behavioral therapy, hypnotherapy, and mindfulness therapy should be considered for IBD patients with functional symptoms 2
• Probiotics may be considered for treatment of functional symptoms in IBD 2, 1
• Physical exercise should be encouraged in IBD patients with functional GI symptoms 2, 1
• Solution-focused therapy for fatigue in quiescent IBD has shown reduction in fatigue for up to 3 months following completion of therapy 2

Surgical Considerations

• Surgery is recommended 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 considered when symptomatic, as it is potentially panenteric and usually recurs following surgery 1

Special Considerations

• IBD patients should be asked about symptoms of fatigue, as it is common and often not reported, and does not necessarily correlate with disease activity 2
• Patients experiencing fatigue should be investigated for subclinical disease activity and other potentially modifiable factors such as sleep pattern, medication side effects, anemia, iron deficiency, and vitamin deficiencies 2
• Type 1 peripheral arthropathy (affecting less than five joints) is usually associated with flares of IBD and responds well to treatment of the underlying disease 2
• Type 2 arthropathy (more than five joints) is usually independent of gut inflammation and may require referral to a rheumatologist for consideration of immunomodulator or biological therapy 2

Treatment Goals and Monitoring

• The primary therapeutic goals are to improve patient quality of life, control inflammation, prevent complications, maintain optimal nutrition, and attempt to modify disease course in those with aggressive disease 3
• Recent advances have led to a paradigm shift in treatment goals, from targeting symptom-free daily life to achieving mucosal healing 7, 5
• Regular self-assessment of the IBD unit should be conducted to see how quality of care and service may be improved 2