Treatment of IBD

Treatment for IBD varies considerably depending on the person, their diagnosis, and the characteristics of their IBD (e.g., location, complications, severity). What works for one person may be ineffective for another. There are many treatment options available, including:

• Steroids (e.g., prednisone, hydrocortisone, budesonide)
• 5-ASAs (e.g., sulphasalazine, mesalazine)
• Immunosuppressants (e.g., azathioprine, methotrexate)
• Biologics (e.g., infliximab, adalimumab)
• Surgery

There are several goals in treating IBD:

• Treatment of acute disease symptoms (i.e., controlling/reducing inflammation, reducing symptoms)
• Improving/maintaining quality of life
• Addressing nutritional deficiencies (e.g., vitamin D, iron)
• Maintaining remission without the use of steroids
• Avoiding complications/hospitalisation/surgery

Treatment of Crohn’s disease

During the diagnostic process, your doctor will assess the type (e.g., Crohn’s), severity, location, and extent of disease activity (i.e., how much of the gut is affected). These factors are important considerations in treating IBD. Depending on your case, your doctor may opt for a graduated (i.e., bottom up) approach to treatment where less aggressive drugs are used first before moving to stronger drugs, if required. Alternatively, your treatment may follow a top-down approach where the initial treatment is aggressive and, after becoming well (i.e., remission), medications are reduced or stopped.

Treatment usually starts with oral inflammatory drugs aimed at inducing remission. These can include 5-ASAs (e.g., Mesalazine), immunosuppressants (e.g., azathioprine, 6-mercaptopurine, methotrexate) and steroids (e.g., budesonide, prednisone). Antibiotics may also be used to treat complications such as fistulae and abscesses. Biologic drugs (i.e., infliximab, adalimumab, ustekinumab or vedolizumab) may be used in more severe cases where other therapies such as steroids and immunomodulators have failed to work. Biologics are often combined with immunosuppressants (i.e., combination therapy) as this may prevent the formation of anti-drug antibodies and improve the efficacy of biologic drugs.

Patients may be admitted to hospital in severe cases of Crohn’s disease where conventional drugs have failed to induce remission. This allows doctors to monitor the patient’s health, treat complications that can arise (e.g., abscesses), provide food and fluids, and administer anti-inflammatory drugs as needed. If treatment with available drugs is remains ineffective, the patient may undergo bowel resection surgery. Although surgery may be a frightening step, it can result in long-term remission and improve quality of life after a period of significant illness.

After achieving remission, you are likely to continue taking a maintenance medication regimen. This typically involves ongoing use of thiopurines (e.g., azathioprine, 6-mercaptopurine), methotrexate, or biologics (e.g., infliximab, adalimumab, ustekinumab, vedolizumab). Steroids are not usually used in maintenance as long-term use can cause adverse effects, such as loss of bone density, weight gain, and mood swings.

Treatment of ulcerative colitis

As with Crohn’s, treatment of ulcerative colitis begins with determining the severity, location and extent of disease activity. These factors are significant for determining the appropriate treatment solution. Treatment aims to reduce symptoms (i.e., achieving remission) and to prevent them from reappearing (i.e., maintaining remission).

Mild to moderate cases are usually treated with 5-aminosalicylic acid (5-ASA) formulations. These include oral forms of 5-ASA (e.g., sulfasalazine, mesalamine, balsalazide, olsalazine) with various release mechanisms (e.g., controlled/delayed/extended release). Oral 5-ASA is often combined with rectally administered forms (suppository, enema), as combined oral and rectal 5-ASA is typically more effective than either alone. Depending on the severity of the disease, 5-ASA treatment may be combined with steroid treatments, such as rectally administered budesonide, oral prednisone or intravenous hydrocortisone/methylprednisolone. Moderate to severe cases are often treated with anti-TNF alpha drugs (e.g., infliximab, adalimumab, golimumab) or vedolizumab.

Surgery may be considered in cases where:

• Aggressive treatments such as oral/IV steroids and biologic drugs are not working
• There are emergency complications such as perforation of the colon (i.e., a tear)
• Cancer or pre-cancerous cells (i.e., dysplasia) are found in the colon

After achieving remission of symptoms, you are likely to continue with a maintenance regimen. This is can be in the form of an oral or rectal 5-ASA, thiopurines (e.g., azathioprine, 6-mercaptopurine), biologics (e.g., infliximab, adalimumab, vedolizumab). Although medication is often required after achieving remission to prevent flare-ups, mild cases with long-term remission and a healthy colon can sometimes allow for treatment to be stopped.