Treatments for Inflammatory Bowel Disease (IBD)

Medical Therapy for IBD Can Include Medications And Surgery

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Most treatments for inflammatory bowel disease (IBD) are either medical or surgical. Many drugs are used in treating both forms of IBD -- Crohn’s disease and ulcerative colitis. When surgery is used to treat IBD, it is more specific to the form of IBD. Surgery is typically only used after all medical options have failed.

Medications

Some of the more common drugs used to treat IBD include sulfasalazine (Azulfadine), mesalamine (Asacol, Pentasa), azathioprine (Imuran), 6-MP (Purinethol), cyclosporine, methotrexate, infliximab (Remicade) and corticosteroids (prednisone).

Sulfasalazine (Azulfidine). Sulfasalazine is known as a 5-aminosalicylate acid (5-ASA) compound, a combination of two drugs (sulfapyridine and an aspirin-like compound [5-ASA]) that reduces inflammation in the colon and helps maintain remission. Common side effects include nausea, headache, diarrhea and abdominal pain.

Mesalamine (Asacol, Pentasa) and Olsazine (Dipentum). These newer drugs in 5-ASA class are as effective as sulfasalazine, but tend to have fewer side effects because they do not contain the sulfa component. Instead, the active ingredient (5-ASA) in mesalamine is enclosed in a resin. The resin does not dissolve until the pill reaches the terminal ileum and the colon, which releases the 5-ASA drug directly where it is needed. Mesalamine is most effective in mild or moderate cases of Crohn’s disease and may decrease the chances of a relapse of Crohn’s disease after surgery. A form of mesalamine approved in January 2007 may be taken once daily for ulcerative colitis instead of the several times a day needed for other forms.

Azathioprine (Imuran), 6-mercaptopurine (Purinethol, 6-MP) and cyclosporine A (Sandimmune, Neoral). Azathioprine, 6-MP and cyclosporine are immunosuppressants—a class of drugs that are used to inhibit the immune system. IBD is an autoimmune disease, and while suppressing the immune system may lessen symptoms, it also leaves the body more susceptible to infection.

Azathioprine and 6-MP are slow acting, and are often combined with another faster-acting drug, such as a corticosteroid. The action of cyclosporine is faster but it is associated with serious side effects. These drugs are most often used to treat Crohn’s disease and used more infrequently for ulcerative colitis.

Methotrexate (Folex, Rheumatrex). Methotrexate is most often given by injection and tends to induce remission in eight to 10 weeks. An oral version of the drug is also available. Side effects range from mild nausea, fatigue and vomiting to more serious bone marrow and liver conditions. Pregnancy should be avoided by both men and women taking methotrexate because it may cause congenital abnormalities and even death in fetuses. If a patient notices a return of symptoms after switching from the injections to the oral version of methotrexate, they should check with their physician. It could be that the oral dose is not being absorbed well enough by their body. Methotrexate is used in Crohn’s disease, but so far no studies have shown a benefit from its use in ulcerative colitis.

Corticosteroids (prednisone, methylprednisolone, etc.). Corticosteroids are similar to cortisol, a steroid the body produces in the adrenal gland. This fast-acting drug reduces inflammation and is usually prescribed to curb an acute flare-up. Slowly tapering the amount of the corticosteroids taken daily allows the body to begin producing cortisol again on its own. Side effects are common with corticosteroids. While taking corticosteroids, some people can experience an overall sense of wellbeing or euphoria, while others can experience a feeling of agitation. Long-term use is associated with fluid retention and a pattern of weight gain that includes obesity in the trunk, buffalo hump, and round face. Steroids can also increase blood sugars, which can be particularly problematic for people who have diabetes or glucose intolerance. Long term use of corticosteroids can cause osteoporosis. Corticosteroids are used to treat both forms of IBD.

Infliximab (Remicade). Infliximab stops tumor necrosis factor (TNF) from being used by the body. TNF is found in higher than typical amounts in people with IBD. Side effects include abdominal pain, nausea, fatigue, vomiting and rarely, infection. Initially developed for Crohn’s disease, infliximab is now approved to treat both forms of IBD.

Budesonide (Entocort EC). Budesonide is used to treat mild to moderate Crohn's disease involving the ileum and/or the ascending colon. Budesonide is a nonsystemic corticosteroid, and because most of the drug is released in the intestine and not the bloodstream, it causes fewer side effects than other corticosteroids. Side effects include headache, respiratory infection, and nausea. Budesonide is used for both forms of IBD.

Surgery

Treatments for IBD also include various surgical options. Ulcerative colitis and Crohn's disease have very different surgical options.

Resection. The most common type of surgery for Crohn’s disease is the resection, during which surgeons remove a diseased piece of the intestine and reconnect the two healthy ends. This type of surgery is not used for ulcerative colitis because the disease will return in the section of the colon that remains.

Strictureplasty. Surgeons use stricturplasty in Crohn’s disease to open up narrowed sections of the intestine (strictures) by making an incision lengthwise along the stricture and closing it in the opposite direction.

Protocolectomy with creation of ileostomy. A protocolectomy is the complete removal of the colon and an ileostomy is the creation of a stoma for eliminating waste. A stoma is the opening in the abdomen through which waste can leave the body from the small intestine. An ostomy bag must be worn on the abdomen to catch waste materials. This type of surgery may be used to treat both Crohn’s disease and ulcerative colitis.

Protocolectomy with creation of pelvic pouch. After the colon is removed to treat ulcerative colitis, an internal pouch may be created out of the last section of the small intestine (the ileum). With this pouch, there is no need for an external ostomy bag. There are several different types of pelvic pouches (j-pouch, BCIR, etc.), but none are appropriate for Crohn’s disease, as the disease may re-occur in the section of the intestine used to create the pouch.

Alternative Treatments

Adjunct treatments for ulcerative colitis can include acupuncture, biofeedback, hypnotherapy, and stress reduction. These therapies are often used in conjunction with medical treatments to help with the tension caused by being diagnosed with a chronic disease.

One experimental treatment that is being studied for use in IBD is fish oil.

The two types of fatty acids found in fish oil have anti-inflammatory properties that are important to several body processes, including blood clotting and immune function.

Other experimental treatments for ulcerative colitis, including aloe vera, butyrate, boswellia, probiotics, antibiotics, immunosuppressive therapy, and nicotine, have not been studied extensively. New therapies for ulcerative colitis may evolve from the ongoing research on these compounds.

Sources:

Bhandari BM, Kroser JA. "Inflammatory Bowel Disease." American College of Gastroenterology. March 2010, March 2011. Cleveland Clinic Foundation. 26 Sept 2013.

NIDDK. "Ulcerative Colitis." National Digestive Diseases Information Clearinghouse. 10 Jul 2013. 26 Sept 2013.

Wolf JL. "Inflammatory Bowel Disease Fact Sheet." The National Women's Health Information Center. 19 Aug 2009. 26 Sept 2013.

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