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 with aminosalicylates, corticosteroids, immunomodulators, biologics, and surgery based on disease severity, location, and pattern. 1

First-Line Treatments

Ulcerative Colitis

• Distal/Mild-Moderate Disease:
  • Topical mesalazine combined with oral mesalazine is the first-line treatment for active distal colitis to provide prompt symptom relief 1
  • Topical corticosteroids can be added to this regimen for enhanced efficacy 1
  • High-dose mesalazine (4g/daily) is recommended for maintenance therapy 1

Crohn's Disease

• Mild Ileocolonic Disease:
  • High-dose mesalazine (4g/daily) may be sufficient as initial therapy 1
• Moderate-Severe Disease:
  • Corticosteroids are indicated for induction of remission 1
  • Consider early introduction of immunomodulators in patients with risk factors for aggressive disease 2

Second-Line and Advanced Treatments

Immunomodulators

• Azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.25 mg/kg/day) should be used for:

  • Steroid-dependent disease 1
  • Maintenance of remission 1
  • Monitor full blood count within 4 weeks of starting therapy and every 6-12 weeks thereafter to detect neutropenia 1
  • Consider TPMT or NUDT15 testing in patients with severe myelosuppression 3
  • Caution: Risk of hepatotoxicity and treatment-related malignancies including hepatosplenic T-cell lymphoma 3

• Methotrexate:

  • 25mg IM weekly for up to 16 weeks, followed by 15mg weekly for chronic active Crohn's disease 1
  • Oral dosing is effective for many patients 1

Biologic Therapies

• Anti-TNF Agents (Infliximab, Adalimumab):
  • Reserved for moderate to severe CD refractory to or intolerant of conventional therapy 1
  • Indicated for treatment of moderately to severely active Crohn's disease in adults and pediatric patients (6 years and older for adalimumab) 4
  • Also indicated for moderately to severely active ulcerative colitis 4
  • Particularly effective for fistulizing perianal Crohn's disease following adequate surgical drainage 1
  • Serious risks include infections (including tuberculosis) and malignancy 4

Management of Severe Disease

Severe Ulcerative Colitis

• Requires hospitalization and intensive therapy:
  • Intravenous corticosteroids are the initial treatment of choice 1
  • Response should be assessed by the third day 1
  • For non-responders, rescue therapy with infliximab in combination with a thiopurine, or ciclosporin should be considered 1
  • Joint management by gastroenterologist and colorectal surgeon is essential 1
  • Patients should be informed of a 25-30% chance of needing colectomy 1

Acute Complications

• Toxic Megacolon:
  • Requires immediate surgical intervention if no clinical improvement after 24-48 hours of medical treatment 1
• Intestinal Perforation or Massive Bleeding:
  • Immediate surgery is mandatory 1
• Intestinal Obstruction:
  • Surgery is indicated for symptomatic strictures that don't respond to medical therapy and aren't amenable to endoscopic dilation 1

Nutritional Support

• Preoperative nutritional support is mandatory in severely undernourished IBD patients 1
• Total parenteral nutrition should be reserved for:
  • Nutritionally deficient patients unable to tolerate enteral nutrition 1
  • When enteral route is contraindicated 1
  • In critically ill patients with signs of shock, intestinal ischemia, high output fistula, or severe intestinal hemorrhage 1
  • When emergency surgery is needed for complicated IBD 1

Surgical Management

• Surgery should be considered when:

  • Medical therapy fails to control symptoms 1
  • Complications such as strictures, fistulas, or abscesses develop 1
  • Dysplasia or carcinoma is present 1

• Surgical principles:

  • Patients requiring surgery are best managed under joint care of a surgeon and gastroenterologist 1
  • For Crohn's disease, resections should be limited to macroscopic disease and be conservative 1
  • For ulcerative colitis, subtotal colectomy is the procedure of choice in acute fulminant disease 1

Maintenance Therapy

• Lifelong maintenance therapy is generally recommended for all patients, especially those with:
  • Left-sided or extensive disease 1
  • Distal disease who relapse more than once a year 1
  • Maintenance therapy reduces the risk of colorectal cancer 1

Common Pitfalls to Avoid

• Overprescription of mesalazine for Crohn's disease when it may not be effective 5
• Inappropriate use of steroids (for perianal Crohn's disease, when there is sepsis, or for maintenance) 5
• Delayed introduction or underdosing with azathioprine, mercaptopurine, or methotrexate 5
• Failure to consider timely surgery when appropriate 5
• Introducing biologic therapy too late in disease progression 5
• Using combination therapy with immunomodulators and anti-TNF agents without considering the increased risk of complications, especially in patients requiring emergency surgery 1

Special Considerations

• Regular monitoring for complications and extraintestinal manifestations is essential 1
• Pain management should address the underlying cause when possible 1
• Surveillance for colorectal cancer should be considered, especially in long-standing ulcerative colitis 1
• Venous thromboembolism prophylaxis with LMWH is recommended for hospitalized patients due to the high risk of thrombotic events 1