Inflammatory Bowel Disease Treatment Overview

Inflammatory Bowel Disease (IBD) Treatment Goals

• Goals of IBD treatment include bowel rest, inflammation control, malnutrition correction, symptom relief, and improved quality of life.
• IBD has no cure. Treatment focuses on medication to control inflammation and maintain remission.

Drug Therapy for IBD

• Drug treatment aims to induce and maintain remission.
• Five major drug classes include aminosalicylates, antimicrobials, corticosteroids, immunomodulators, and biologics.
• Drug choice depends on inflammation location and severity.
• Initial UC treatment often includes corticosteroids and either aminosalicylates or biologics, severity-dependent. Crohn's management also includes corticosteroids and biologics.
• Drugs can be used alone or in combination.

5-Aminosalicylic Acid (5-ASA) Drugs

• 5-ASA drugs treat both UC and Crohn's, being more effective in UC.
• Exact mechanism unclear, thought to suppress proinflammatory cytokines and other inflammatory mediators.
• Available orally and rectally. Oral forms have different coatings for targeted GI tract release, increasing effectiveness. Rectal delivery targets inflamed rectal/large intestinal tissue.
• Combined oral and rectal therapy is often better than either alone.

Biologic Therapies for IBD

• These therapies reduce IBD inflammation by blocking specific inflammation-related proteins.
• Four main classes: anti-TNF agents, alpha 4-integrin inhibitors, IL-12/23 antagonists, and JAK inhibitors.
• Anti-TNF agents (e.g., infliximab) are typically administered intravenously.
• Side effects: upper/lower respiratory infections, headaches, nausea, joint pain, abdominal pain, hepatitis/tuberculosis reactivation, opportunistic infections, potential cancers (especially lymphoma). Screening for Hepatitis and TB before treatment is crucial.
• Live virus immunizations are contraindicated. Education on infection prevention and signs is needed.
• Alpha 4-integrin inhibitors (e.g., natalizumab, vedolizumab) are given intravenously. Limited to those who do not respond to other therapies. Increased risk for infection, liver toxicity, and hypersensitivity noted. Natalizumab has restricted access due to progressive multifocal leukoencephalopathy risk.
• IL-12/23 antagonists (ustekinumab, risankizumab) target IL-12 and IL-23 preventing T-helper and natural killer cell activation.
• JAK inhibitors (tofacitinib) are a newer type that block the JAK enzyme. Prevent activation of specific inflammatory immune cells. TB testing required before tofacitinib use. Contraindicated with other biologics/immunomodulators.

Corticosteroids in IBD

• Corticosteroids decrease intestinal inflammation and are used short-term.
• Local delivery (suppositories, enemas, foams) may be better for left-sided colon/sigmoid/rectal disease as they minimize systemic effects.
• Oral prednisone is for moderate/mild disease unresponsive to 5-ASA.

Immunomodulators in IBD

• These drugs maintain remission after corticosteroid use.
• Useful for those unresponsive to 5-ASA/corticosteroids/antibiotics, who have side effects from corticosteroids, or those with fistulas.
• Delayed onset of action, not useful for acute flares.
• Require CBC monitoring for bone marrow suppression, infection, bleeding risks. Possible liver/pancreas problems. Flu-like symptoms. Women of childbearing age should avoid pregnancy with methotrexate due to birth defects/fetal death risk.

Hospitalization for IBD

• Hospitalization may be needed if patients fail drug therapy, have severe disease, or suspected complications.

IBD Surgical Therapy (General)

• Surgical treatment is often required for complications of Crohn's disease (obstructions) and for unresponsive disease.
• UC has surgical cure options (proctocolectomy with IPAA/ileostomy).
• Crohn's frequent reoccurrence at surgical anastomosis site.
• Short bowel syndrome (SBS) is a potential complication from repeated bowel resections.
• Strictureplasty helps open narrowed obstructions, reducing SBS risk but has potential for recurrent issue.