What is the recommended approach for managing Inflammatory Bowel Disease (IBD) in patient management?

Management of Inflammatory Bowel Disease in Patients

For Crohn's disease with moderate to severe activity, initiate advanced therapy (biologics or small molecules) early rather than following traditional step-up approaches, as this strategy improves long-term outcomes and prevents bowel damage. 1

Initial Disease Assessment and Classification

Crohn's Disease Assessment:

• Evaluate disease location (ileal, colonic, ileocolonic), behavior pattern (inflammatory, stricturing, penetrating), and activity level using objective markers including faecal calprotectin, intestinal ultrasound, MRE, or ileocolonoscopy 1
• Small bowel assessment requires radiology by follow-through or small bowel enema as the current standard 1

Ulcerative Colitis Assessment:

• Define disease extent by the proximal margin of macroscopic inflammation, classified as distal or extensive disease 1, 2
• This classification determines optimal route of therapy delivery 1

Treatment Approach for Crohn's Disease

Mild Disease

• High-dose mesalazine 4g daily as initial therapy 2, 3
• However, note that mesalazine has limited benefit in Crohn's disease overall 2, 4

Moderate to Severe Disease

The 2025 British Society of Gastroenterology guidelines represent a paradigm shift away from traditional corticosteroid-first approaches:

• Initiate advanced therapy (biologics or small molecules) as first-line treatment for moderate to severe disease 1
• This early effective treatment approach is superior to traditional step-up therapy for long-term disease control 1

If corticosteroids are used (now considered second-line):

• Systemic corticosteroids: prednisolone 40mg daily for no longer than 8 weeks 1, 2
• Budesonide: for mild ileocaecal disease only, maximum 12 weeks 1
• Critical caveat: Whenever prescribing systemic corticosteroids, simultaneously consider whether advanced therapy initiation or change is required 1
• Avoid repeated steroid courses unless futility of other effective therapies has been established 1

Maintenance of Remission

• Smoking cessation is crucial 2
• Azathioprine 1.5-2.5mg/kg/day or mercaptopurine 0.75-1.5mg/kg/day as effective maintenance options 2
• Corticosteroids are NOT recommended for maintenance 1

Monitoring Strategy

• Frequent monitoring using faecal calprotectin, intestinal ultrasound, MRE, or ileocolonoscopy to identify ongoing inflammation requiring therapy optimization 1
• Regular disease monitoring is essential even for patients on advanced therapies to detect ongoing activity or bowel damage progression 1

Treatment Approach for Ulcerative Colitis

Distal (Left-sided) Disease

• First-line: Combination of topical mesalazine 1g daily PLUS oral mesalazine 2-4g daily 2, 5
• This combination approach is more effective than either treatment alone 5
• Topical corticosteroids for patients intolerant to topical mesalamine 5

Extensive Disease

• Oral mesalazine 2-4g daily or balsalazide 6.75g daily 2
• For inadequate response: oral prednisolone 40mg daily with gradual tapering over 8 weeks 5

Severe Disease

• Requires hospital admission with joint management between gastroenterologist and colorectal surgeon 2
• Intravenous fluid and electrolyte replacement 5
• Intravenous corticosteroids 5
• Close monitoring with regular laboratory assessments 5
• Subcutaneous heparin to reduce thromboembolism risk 5
• Nutritional support 5

Maintenance of Remission

• Lifelong maintenance therapy recommended for left-sided or extensive UC 2
• Options include aminosalicylates, azathioprine 1.5-2.5mg/kg/day, or mercaptopurine 0.75-1.5mg/kg/day 2, 5
• All 5-ASA derivatives show comparable efficacy, with sulphasalazine having modest therapeutic advantage (OR 1.29) 1
• Maintenance therapy may reduce colorectal cancer risk by up to 75% (OR 0.25), favoring long-term treatment for extensive UC 1

Pediatric IBD Management

Pediatric Crohn's Disease:

• Infliximab 5mg/kg at 0,2, and 6 weeks, then every 8 weeks 6

Pediatric Ulcerative Colitis:

• Infliximab 5mg/kg at 0,2, and 6 weeks, then every 8 weeks 6

Biologic Therapy: Infliximab

Dosing for Adult IBD:

• 5mg/kg at 0,2, and 6 weeks, then every 8 weeks 6
• Some patients who initially respond may benefit from dose escalation to 10mg/kg if they lose response 6

Critical Safety Warnings:

• Screen for latent tuberculosis before initiation; treat if positive 6
• Monitor all patients for active TB during treatment, even if initial test negative 6
• Discontinue if serious infection develops 6
• Increased risk of lymphoma and other malignancies, particularly hepatosplenic T-cell lymphoma in young males receiving concomitant azathioprine or 6-mercaptopurine 6
• Contraindicated in doses >5mg/kg with moderate to severe heart failure 6

Surgical Considerations

Ulcerative Colitis:

• Indicated for disease not responding to intensive medical therapy, dysplasia/carcinoma, or poorly controlled disease 2
• Requires joint management between surgeon and gastroenterologist 2
• Can be curative with complete resection of involved colon 7

Crohn's Disease:

• Limited to symptomatic disease with conservative resections of macroscopic disease only 2
• Typically reserved for complications or refractory disease 7

Pouchitis Management (Post-Surgical Complication)

Acute Pouchitis:

• Ciprofloxacin as first-line treatment (better tolerated and may be more effective than metronidazole) 1
• Alternative: metronidazole 1

Chronic Refractory Pouchitis:

• Combination antibiotics (ciprofloxacin, metronidazole, tinidazole, rifaximin) 1
• Oral budesonide or oral beclometasone 1
• If not responding to antibiotics or locally-acting corticosteroids, consider advanced immunosuppressive therapies with vedolizumab as first-line 1

Multidisciplinary Team Structure

Essential team members for optimal IBD care:

• Gastroenterologists with IBD expertise 1
• Colorectal surgeons 1
• Rheumatology, dermatology, ophthalmology consultants for extraintestinal manifestations 1
• Nutrition specialists 1
• Gynaecology/urology for complex cases 1
• Psychology support 1

Cancer Surveillance

• Colonoscopy after 8-10 years to re-evaluate disease extent 2
• Surveillance colonoscopy decisions individualized based on patient risk factors 2

Common Pitfalls to Avoid

• Overprescription of mesalamine for Crohn's disease (limited efficacy) 4
• Inappropriate steroid use: for perianal CD, when sepsis present, or for maintenance therapy 4
• Delayed introduction or underdosing of azathioprine, 6-mercaptopurine, or methotrexate 4
• Failure to consider timely surgery 4
• Inappropriate anti-TNF use: when sepsis or fibrostenotic strictures present 4
• Paradoxically, introducing anti-TNF therapy too late in disease progression 4
• Rapid steroid tapering associated with early relapse; taper over 8 weeks minimum 5
• Failing to exclude infectious causes before attributing symptoms to IBD flare and escalating therapy 5