The treatment of Inflammatory Bowel Disease requires a cooperative, team approach between the patient, gastroenterologist, and surgeon. By working together, the patient will be better able to make decisions regarding the proper treatment by assessing the type, severity, and complications of Inflammatory Bowel Disease. Each treatment will be different, and will depend on patient factors such as age, comorbidities, and personal preference.
The goals of treatment are to:
- Relieve symptoms
- Treat inflammation – induce remission
- Maintain remission
- Prevent complications
- Treat complications
- Minimize medication side effects
- Maintain adequate nutrition
- Improve quality of life
Drugs used to treat Inflammatory Bowel Disease include:
- Antibiotics –commonly used for perianal Crohn’s disease. Antibiotics commonly used include: ciprofloxacin, metronidazole, amoxicillin, and rifaximin
- Aminosalicylates –compounds that contain 5-aminosalicylic acid (5-ASA) which has anti-inflammatory properties. Aminosalicylates are effective to treat mild-to-moderate ulcerative colitis. It can be given orally and/or rectally (suppositories and liquid enemas)
- Corticosteroids – drugs such as prednisone (oral), hydrocortisone (foam enema), and methylprednisolone (intravenous). Corticosteroids are used to induce remission in moderate-to-severe ulcerative colitis and Crohn’s disease. Corticosteroids are not used for maintenance of remission as they have many side effects. These side effects include high blood pressure, diabetes, osteoporosis, facial swelling, insomnia, excessive facial hair, and increase in infection and mortality.
- Thiopurines – immunomodulators that weaken the immune system. Thiopurines are used to maintain remission in mild-to-moderate ulcerative colitis and Crohn’s disease. It is often used in combination with biologics for moderate-to-severe ulcerative colitis and Crohn’s disease. Since it weakens the immune system, lab monitoring of the bone marrow and liver needs to be done periodically.
- Methotrexate –immunomodulator used to maintain remission in mild-to-moderate ulcerative colitis and Crohn’s disease. It is often used in combination with biologics for moderate-to-severe ulcerative colitis and Crohn’s disease. Lab monitoring of the bone marrow and liver needs to be done periodically.
- Anti-TNF – Infliximab (Remicade), Adalimumab (Humira), Golimumab (Symponi), Certolizumab (Cimzia). Anti-TNF agents are antibodies that block certain proteins of the immune system and are used to treat moderate-to-severe ulcerative colitis and Crohn’s disease. It is often used in combination with an immunomodulator. Anti-TNF agents are given intravenously (infliximab) or as a subcutaneous injection (adalimumab, certolizumab, golimumab). Anti-TNF agents can reactivate tuberculosis, hepatitis B, and fungal infections. Therefore, your doctor will screen you for these infections prior to starting treatment.
- Anti-Integrins –Anti-Integrins are antibodies that block certain proteins of the immune system and are used to treat moderate-to-severe ulcerative colitis and Crohn’s disease. They are given as intravenous infusions. Natalizumab has been associated with a central nervous condition called progressive multifocal leukoencephalopathy (PML). Therefore, your doctor will screen you and enroll you in a program prior to treatment with Natalizumab.
- Ustekinumab (Stelara) –an antibody that blocks a certain protein in the immune system and has been approved to treat psoriasis. Studies have also shown that it is effective in the treatment of moderate-to-severe Crohn’s disease.
Other medications used in treatment can include:
- Anti-diarrheals – anti-diarrheals such as loperamide or Lomotil can be used to help manage your diarrhea. Please discuss these with your doctor before starting.
- Pain relievers – non-steroidal agents (ibuprofen, naproxen, and diclofenac) can exacerbate your Inflammatory Bowel Disease and should be avoided. Narcotics (oxycodone, hydrocodone, morphine, hydromorphone, fentanyl, and tramadol) have been shown to increase mortality in patients with Inflammatory Bowel Disease and therefore are best avoided. Tylenol is safe to use in low doses (less than 2-4grams per day).
- Vitamins and supplements – your doctor may supplement your diet with iron, vitamin B12, calcium, and vitamin D based on your lab tests. Please discuss all supplements with your doctor prior to taking.
Some patients may require surgery despite maximum medical treatment.
Surgery can be used to treat:
- Ulcerative colitis – Since ulcerative colitis is confined to the colon, removing the entire colon surgically can be done in medically refractory disease. This type of surgery usually includes taking out the entire colon and rectum (total proctocolectomy) and connecting the small bowel with the anus (ileoanal anastomosis) by creating a pouch. If creating a pouch is not feasible, the small bowel is brought to the skin where the stool is collected in an ostomy bag.
- Crohn’s disease – Surgery in Crohn’s disease is not curative. The benefit of surgery in Crohn’s disease is temporary and Crohn’s disease usually returns over time. Therefore, patients often require medical therapy after surgery to help prevent recurrence of disease.
There are different types of surgeries in Crohn’s disease depending on the location of disease and associated complications.
These different surgeries could be:
- Stricturoplasty – involves cutting the bowel lengthwise to widen a narrowed area of bowel
- Small and/or large bowel resections – involves removing the inflamed bowel surgically and reconnecting the healthy bowel
- Perianal fistula and abscess – surgeons perform an exam under anesthesia where they can incise and drain abscesses and place setons (silk or rubber string) in fistulas to help drain infection
While conventional treatments are always preferred to surgery, a surgical procedure will not always be the answer either. There have been other methods tested for effectiveness against IBD, though not always successful.
These other methods include:
- Probiotics – Probiotics have not been found to prevent or treat Inflammatory Bowel Disease
- Medical Marijuana – Medical Marijuana has not been found to induce remission in Crohn’s disease. Many patients report that marijuana provides significant benefit for poor appetite, nausea, and abdominal pain; however, improvement in diarrhea is less clear. In 2015, Louisiana became the first state in the Deep South allowing legal access to medical marijuana for some conditions, although it is not immediately available to patients who qualify. The law, as written, does not cover patients with Crohn's disease; however, the number of covered diseases could expand in the next legislative session.
- Fecal transplant – There are conflicting data whether fecal transplant induces remission in ulcerative colitis. More research is needed.
- Acupuncture – Small studies show some benefit in Crohn’s disease and ulcerative colitis.
- Helminths – Currently, there is insufficient evidence to allow any firm conclusions regarding the efficacy and safety of helminths used to treat patients with Inflammatory Bowel Disease. More research is needed.