What is the management of Inflammatory Bowel Disease (IBD)?

Management of Inflammatory Bowel Disease

Organizational Framework

Establish a multidisciplinary team (MDT) as the foundation of IBD care, including at minimum: two gastroenterologists, two colorectal surgeons, 2.5 IBD nurses, 1.5 stoma nurses, 0.5 dietitian, 0.5 administrative support, one histopathologist, one radiologist, and one pharmacist per 250,000 population. 1

• The wider MDT should include psychologist, pediatric IBD team, obstetrician, rheumatologist, and dermatologist with arrangements for coverage during absences 1
• MDT meetings must occur weekly or frequently enough to prevent delays in decision-making 1
• Provide rapid access to clinic appointments for new symptoms and disease relapses 2
• Ensure direct telephone access to the care team for urgent concerns 2
• Maintain continuity of care with the same clinician whenever possible 2

Ulcerative Colitis Management

Mild to Moderate Distal Disease

Start with combination therapy: topical mesalazine 1g daily PLUS oral mesalazine 2-4g daily as first-line treatment. 3, 4

• This combination is superior to either agent alone for prompt symptom relief 3
• Add topical corticosteroids as second-line for patients intolerant of topical mesalazine 3, 4
• If combination mesalazine therapy fails, escalate to oral prednisolone 40mg daily, tapered gradually over 8 weeks based on response 3, 4

Severe Ulcerative Colitis

Admit immediately for intravenous corticosteroids without delay for stool cultures. 4, 2

• Joint management by gastroenterologist and colorectal surgeon is mandatory from admission 4, 2
• Monitor vital signs four times daily with daily stool charts 4
• Obtain labs (complete blood count, CRP, electrolytes, albumin) every 24-48 hours 4
• Perform daily abdominal radiographs if colonic dilatation >5.5cm is detected 4
• Provide IV fluid/electrolyte replacement and transfuse to maintain hemoglobin >10g/dL 4
• Administer subcutaneous low molecular weight heparin for thromboembolism prophylaxis in all hospitalized patients 4, 2
• Assess response by day 3; if no improvement, initiate rescue therapy with infliximab or ciclosporin immediately. 3, 4, 2
• Inform patients of 25-30% colectomy risk 4

Maintenance Therapy for UC

Prescribe lifelong aminosalicylate maintenance with mesalazine ≥2g daily (high-dose 4g daily preferred) for all patients, especially those with left-sided or extensive disease. 3, 4, 2

• This reduces colorectal cancer risk 3, 2
• For steroid-dependent patients, use azathioprine 1.5-2.5mg/kg/day or mercaptopurine 0.75-1.5mg/kg/day 3, 4, 2

Surgical Indications for UC

Operate for disease not responding to intensive medical therapy, dysplasia, or carcinoma. 4, 2

• Subtotal colectomy with long rectal stump is the procedure of choice for acute fulminant disease 4, 2
• Counsel regarding ileo-anal pouch for elective surgery 4

Crohn's Disease Management

Mild Ileocolonic Disease

High-dose mesalazine 4g daily may be sufficient as initial therapy for active mild ileocolonic Crohn's disease. 3, 4

• Consider nutritional therapy, antibiotics, or corticosteroids based on patient preference and disease characteristics 4

Moderate to Severe Disease

Use corticosteroids for induction of remission; budesonide is preferred for ileal/right-sided colonic disease due to lower systemic effects. 3, 4

• Never use corticosteroids for maintenance—they are ineffective and cause steroid dependency. 4

Steroid-Dependent or Refractory Disease

Second-line: Azathioprine 1.5-2.5mg/kg/day or mercaptopurine 0.75-1.25mg/kg/day for steroid-dependent disease and maintenance of remission. 3, 4

• Alternative: Methotrexate 25mg IM weekly for up to 16 weeks, then 15mg weekly for chronic active disease or azathioprine intolerance 3, 4
• Add folic acid 5mg weekly (3 days after methotrexate) to reduce side effects 4

Anti-TNF Therapy

Reserve infliximab or adalimumab for moderate to severe Crohn's disease refractory to or intolerant of conventional therapy (steroids, mesalazine, and immunomodulators) where surgery is inappropriate. 3, 5

• Infliximab dosing: 5mg/kg at weeks 0,2, and 6 for induction 3, 4
• Maintenance: 5-10mg/kg every 8 weeks for responders 4
• Adalimumab is FDA-approved for treatment of moderately to severely active Crohn's disease in adults and pediatric patients 6 years of age and older 5
• Use anti-TNF agents as part of comprehensive strategy including immunomodulation and surgical consultation 4
• Effectiveness has not been established in patients who have lost response to or were intolerant to TNF blockers. 5

Perianal/Fistulating Disease

First-line: Metronidazole 400mg three times daily and/or ciprofloxacin 500mg twice daily for simple perianal fistulae. 4

• Obtain MRI and examination under anesthesia to define anatomy 4
• Use azathioprine/mercaptopurine for simple fistulae after excluding distal obstruction and abscess 4
• For refractory fistulae: Infliximab (three infusions at 0,2,6 weeks) combined with immunomodulation and surgical drainage 4
• Consider seton drainage, fistulectomy, or advancement flaps for persistent/complex fistulae 4

Maintenance Therapy for CD

All smokers must stop—this is the most important factor in maintaining remission. 4

• Mesalazine has limited benefit, ineffective at <2g/day or after steroid-induced remission 4
• Azathioprine/mercaptopurine effective but reserved as second-line due to toxicity 4
• Methotrexate 15-25mg IM weekly for patients who responded to IM methotrexate induction 4

Surgical Management for CD

Operate only for symptomatic disease, not asymptomatic radiologic findings. 4, 2

• Resections limited to macroscopic disease only—be conservative 4, 2
• Avoid primary anastomosis in presence of sepsis and malnutrition 4
• Consider stricture dilatation or strictureplasty for diffuse small bowel disease 4

Special Populations

Pediatric IBD

For polyarticular JIA: Adalimumab is indicated for reducing signs and symptoms in patients 2 years of age and older. 5

• For Crohn's disease: Adalimumab is approved for patients 6 years of age and older 5
• For ulcerative colitis: Adalimumab is approved for patients 5 years of age and older 5
• For hidradenitis suppurativa: Adalimumab is approved for patients 12 years of age and older 5
• Post-marketing cases of lymphoma, including hepatosplenic T-cell lymphoma and other malignancies (some fatal), have been reported among children, adolescents, and young adults receiving TNF-blockers 5

Pregnancy and Breastfeeding

Treat both maintenance and flares during pregnancy as normal with 5-ASA, thiopurines, anti-TNF, nutrition, and steroids. 1

• Adalimumab actively crosses the placenta; cord blood concentrations are typically higher than maternal serum concentrations 5
• Adalimumab can be detected in infant serum for at least 3 months from birth after in utero exposure 5
• Limited data show adalimumab is present in human milk at infant doses of 0.1% to 1% of maternal serum concentration 5
• The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for adalimumab 5
• Consider risks and benefits prior to administering live or live-attenuated vaccines to infants exposed to adalimumab in utero. 5

Critical Safety Considerations

Administer low molecular weight heparin for all hospitalized IBD patients due to high thrombotic risk. 3, 2

• VTE prophylaxis is particularly important after Caesarean section 1
• Monitor patients on immunomodulator therapy (azathioprine, mercaptopurine) for safety and efficacy 2

Long-Term Monitoring

Implement regular surveillance for complications, extraintestinal manifestations, and colorectal cancer screening. 3, 2

• Maintenance therapy reduces colorectal cancer risk in IBD patients 3, 2
• Audit outcomes including proportion of patients on immunomodulator therapy, outcome of admission for severe colitis, time lost to work, and mortality 2

Common Pitfalls to Avoid

• Do not delay admission for severe UC to obtain stool cultures 4, 2
• Do not use corticosteroids for maintenance therapy in Crohn's disease 4
• Do not perform surgery for asymptomatic radiologic findings in Crohn's disease 4
• Do not use mesalazine at doses <2g/day for Crohn's disease maintenance 4
• Do not ignore smoking cessation counseling—it is the most critical intervention for Crohn's disease remission 4