Inflammatory Bowel Disease (IBD): Treatment Options
Treatment of IBD may be divided into two parts:
1. Induction of remission (getting a patient well)
2. Maintenance of remission (keeping a patient well)
Medications
Here, we describe some of the medications commonly used for the treatment of IBD:
- 5-aminosalicylates (5-ASAs) are very effective first-line therapy for induction and maintenance of remission for ulcerative colitis. While they are less
effective in Crohn's disease, they may be prescribed in patients with mild disease and particularly those with colonic inflammation.
These medications may be given orally and/or rectally (suppository or enema). For most patients, there are few, if any, side
effects.
- Glucocorticosteroids (e.g., prednisone) are very effective for the induction of remission in patients with both ulcerative colitis and Crohn's
disease. However, they are not effective in maintaining remission and are also associated with many side effects - including
some that are potentially serious. Thus, these medications should be used for as short a period as possible.
- Antibiotics may be of benefit to patients with Crohn's disease, especially those with colonic involvement and “perianal” (around the
anus) disease, including fistulas and abscesses. Commonly used antibiotics include ciprofloxacin and metronidazole (Flagyl®).
- Immunomodulators are a group of medications that includes 6-mercaptopurine (6-MP), azathioprine (Imuran®), and methotrexate. They are commonly
prescribed when patients require one or more courses of glucocorticosteroids or in those who have become “steroid-dependent”
in an effort to maintain remission without steroids. These medications may take two to three months to effect clinical change
and rarely have been associated with adverse reactions such as serious infection or lymphoma. For the vast majority of patients,
it is believed that the benefits of these medications greatly outweigh the risks. It is important for all patients to discuss
these issues with their doctors before starting immunomodulators. Patients taking these medications should be monitored regularly
with routine blood tests.
- Biologics include the “anti-tumor necrosis factor alpha (TNFα)” antibodies, of which there are now three available for the treatment
of Crohn's disease: infliximab (Remicade®), adalimumab (Humira®), and certolizumab (Cimzia®). Only infliximab is also approved
for the treatment of ulcerative colitis. These medications block TNFα, a protein in the body that increases inflammation in
patients with IBD. They are effective in both the induction and maintenance of remission in patients with moderate to severe
IBD. They may be used in conjunction with an immunomodulator or alone. Like the immunomodulators, the anti-TNFαs have been
associated with a small increased risk for reactions or complications; proper precautions and monitoring for any adverse events
are essential.
- Natalizumab (Tysabri®) is the newest biologic agent to be approved for the treatment of Crohn's disease, and it is effective in the induction and
maintenance of remission for patients with severe illness who do not respond or cannot tolerate the anti-TNF medications.
It works by decreasing the influx of inflammatory cells from the bloodstream into the gut. The major risk associated with
this medication is a brain infection called Progressive Multifocal Leukoencephalopathy (PML), which fortunately is an exceedingly
rare event; all patients are required to adhere to a strict risk management program.
Surgery
While we strive to avoid surgery if possible in patients with IBD, as many as 70% of patients with Crohn's disease will need
an operation at some time in their lifetime. One of the most common types of surgery is drainage of abscesses that can develop
around the anus; sometimes the surgeon will place a small rubber band (called a seton) through this abnormal opening to aid
in its healing. Another common type of surgery for Crohn's is the removal of the end of the small bowel (the terminal ileum)
and first part of the colon (called the cecum). This surgery is often performed when the ileum has narrowed to the point of
causing obstruction.
Up to a quarter of patients with ulcerative colitis will require surgery over their lifetime. Surgery is most commonly performed
because of continued symptoms and inflammation despite maximal medical therapy or secondary to precancerous changes or cancer
in the colon. Even if only a small portion of the colon is involved, the proper surgery for patients with ulcerative colitis
is removal of the entire colon (colectomy). Otherwise healthy and non-elderly patients may be candidates a j-pouch procedure
which maintains fecal continence; other patients may need to have an ileostomy.
Clinical trials
Through Thomas Jefferson University, the Inflammatory Bowel Disease team is able to offer patients the option of participating
in clinical trials.
Schedule an appointment
To schedule an appointment with the Inflammatory Bowel Disease Program of the Jefferson Digestive Disease Institute in Philadelphia,
call 1-800-JEFF-NOW or use our online appointment request form.
