What are the treatment options for Inflammatory Bowel Disease (IBD)?

From the Guidelines

Treatment for IBD should prioritize biologic therapies, such as anti-tumour necrosis factor (TNF) agents, as they have shown to be effective in reducing inflammation and preventing complications, according to the most recent guidelines 1. When managing IBD, it's essential to consider the potential for complications, such as strictures, fistula, or abscesses, which can occur in up to one-third of patients at diagnosis. The goal of treatment is to reduce inflammation, induce and maintain remission, and improve quality of life.

• Medical agents, including mesalazine, locally active steroids, systemic steroids, thiopurines, methotrexate, and biologic therapies, are available for the treatment of IBD.
• Biologic therapies, such as anti-TNF agents, have been shown to be effective in reducing inflammation and preventing complications, and are often used in combination with other medications.
• The choice of treatment should be individualized based on disease severity, extent, and patient preferences, as well as the potential for complications and the need for surgery.
• Regular monitoring of symptoms and medication effectiveness is crucial, as treatment plans often need adjustment based on disease activity and individual response, as stated in the ECCO guidelines on therapeutics in Crohn's disease: medical treatment 1.

From the FDA Drug Label

HUMIRA is a tumor necrosis factor (TNF) blocker indicated for: ... Ulcerative Colitis (UC) (1. 6): treatment of moderately to severely active ulcerative colitis in adults and pediatric patients 5 years of age and older.

Mercaptopurine is mutagenic in animals and humans, carcinogenic in animals, and may increase the patient's risk of neoplasia. Cases of hepatosplenic T-cell lymphoma have been reported in patients treated with mercaptopurine for inflammatory bowel disease.

Treatment for IBD-C (Inflammatory Bowel Disease - Colitis):

• Adalimumab (HUMIRA): is indicated for the treatment of moderately to severely active ulcerative colitis in adults and pediatric patients 5 years of age and older 2.
• Mercaptopurine: has been reported to have cases of hepatosplenic T-cell lymphoma in patients treated for inflammatory bowel disease, but its safety and efficacy in patients with inflammatory bowel disease have not been established 3.

Key points:

• Adalimumab is approved for the treatment of ulcerative colitis.
• Mercaptopurine has potential risks and its use in IBD is not established.

From the Research

Treatment for Inflammatory Bowel Disease (IBD)

• Aminosalicylates, such as mesalamine, are a foundational strategy for the induction and maintenance of remission in mild to moderate ulcerative colitis 4.
• Topical mesalamine is the most efficacious approach to distal ulcerative colitis, while orally delivered azo conjugates may have an advantage over pH-released mesalazine as a first-line approach to active disease 4.
• Aminosalicylates have been advocated for several decades in Crohn's disease, but their role in maintenance therapy has not been as firmly established, and they are less efficacious than corticosteroids at inducing remissions 4.
• Conventional therapies for IBD include aminosalicylates, corticosteroids, thiopurines, methotrexate, and anti-tumor necrosis factor agents, and a time-structured approach is required for appropriate management 5.

Aminosalicylates in IBD

• Aminosalicylates have been shown to exhibit a wide range of anti-inflammatory and immunomodulatory properties, and are now first-line therapies for the treatment of mildly to moderately active IBD and for maintenance of remissions after successful induction therapy 6.
• Mesalamine and olsalazine are 5-aminosalicylic acid agents that have been developed to treat IBD, and have been shown to be effective in clinical trials 7.
• The exact mechanism of action of these agents in the treatment of IBD is unknown, but they are thought to have anti-inflammatory and immunomodulatory effects 7.

Common Misconceptions about 5-Aminosalicylates and Thiopurines

• Misconceptions are common in the care of patients with IBD, and include the use of 5-aminosalicylates in patients with small bowel Crohn's disease, and the underdosing of thiopurines 8.
• The combined approach with oral plus topical 5-aminosalicylates should be the first-line therapy in patients with active ulcerative colitis, and once-daily treatment should be offered as a first choice regimen due to its better compliance and higher efficacy 8.
• Thiopurines seem to be as effective in ulcerative colitis as in Crohn's disease, and should probably be continued indefinitely because their withdrawal is associated with a high risk of relapse 8.