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Crohn's Disease

How Is Crohn's Disease Treated?

Last modified: 
21/03/2012 - 13:35

Contributing Author: Guy Slowik FRCS

Medical management of Crohn's disease focuses on reducing symptoms and bringing on a remission. Once this is accomplished, the goal is to maintain remission for as long as possible. Most of the medications used to treat Crohn's disease are generally safe for long-term use. Many doctors keep individuals on maintenance doses of medications indefinitely.

Medications commonly used to treat Crohn's disease include:

Alternative treatments

5-ASA Compounds

A number of medications used to treat Crohn's disease and ulcerative colitis have as their active ingredient 5-aminosalicylic acid (5-ASA), an agent that inhibits substances in the immune system that cause inflammation. These include sulfasalazine (trade name Azulfadine), a compound that has been used for more than half a century.

Sulfasalazine is a so-called "sulfa drug." The sulfapyradine (an antibacterial organic sulfur compound) in sulfasalazine causes a number of side effects, which range from mild to severe headaches, nausea, and vomiting. These are usually dose-related, although some people cannot tolerate the medication at all. Azulfadine can be purchased in an enteric-coated tablet, which (for many people) reduces the incidence of nausea caused by uncoated tablets. For years, scientists sought ways to deliver 5-ASA without the sulfa-drug side effects.

During the 1990s, a number of new 5-ASA medications were approved. None are yet available as generics. They can be found under the following trade names and in the following formulations:

  • Asacol (mesalamine), available as a 400-milligram coated caplet
  • Pentasa (mesalamine), available as a 250-milligram capsule
  • Rowasa (mesalamine), available as a 500-milligram rectal suppository or a 4,000 milligram enema (effective for Crohn's colitis, which affects the rectum and left side of the colon)
  • Dipentum (osalazine), available as a 250-milligram capsule

Evidence shows that all of the new 5-ASA compounds are effective in large doses for treatment of flare-ups and in lower doses for maintenance therapy. Because these medications are expensive, many doctors prefer to try sulfasalazine first. The chemical structure of mesalamine is similar to aspirin; people with an allergy to aspirin should inform their doctors.

Steroids

Steroids are powerful, potentially toxic drugs that reduce inflammation and suppress the body's immune system. Prednisone and prednisolone are the most commonly used steroids for treatment of Crohn's disease and ulcerative colitis. While they are very useful, steroids can produce a number of side effects ranging from annoying to dangerous.

  • Annoying side effects include puffiness in the face, acne, insomnia, tremors, night sweats, weight gain, and mood disturbances.
  • Dangerous side effects include increased blood pressure, osteoporosis, severe depression, and even psychosis. Long-term steroid use can cause cataracts and glaucoma.

Steroids are used to treat moderate-to-severe symptoms during a flare-up. These drugs have not been shown to be beneficial as a maintenance therapy, and individuals are weaned off of steroids as quickly as possible after remission is achieved.

Medications To Suppress The Immune System

Immunosuppressive drugs are powerful compounds that override the body's natural immune defenses. They are widely known for their use in conjunction with organ transplants to reduce the possibility of rejection.

In the 1960s, gastroenterologists began experimenting with immunosuppressive drugs for treatment of both Crohn's disease and ulcerative colitis. Today, doctors continue to refine the dosages used in treating inflammatory bowel disease. In these lower doses, the drugs are considered "immunoregulators" rather than immunosuppressives. Generally, immunoregulatory drugs are used more often in treating Crohn's disease than ulcerative colitis.

Immunoregulatory drugs are often prescribed in conjunction with steroids. Steroids are required initially, because it can take months for immunoregulatory drugs to take effect. But a lower dose of steroids can be administered, and they can be discontinued more quickly without inducing a relapse. Immunoregulatory therapy is then effective for maintaining remission and may help heal fistulas and fissures. Following this regimen, which would likely include the antimetabolite 6-mercaptopurine (6-MP, sold under the trade name Purinethol), can reduce the number of people who are steroid-dependent in the long term.

Antibiotics

Recent research points to bacteria as an important element in Crohn's disease. This may involve bacterial agents triggering the inflammatory process, or a reaction against the normal bacterial that live in the intestine. In addition, when the ileocecal valve is damaged, as often occurs in ileitis or ileocolitis, there may be a backup of contents from the colon into the small intestine, leading to a condition known as bacterial overgrowth.

For these reasons, antibiotic treatment is becoming increasingly common in Crohn's disease. Broad-spectrum antibiotics such as ciprofloxacin (Cipro), clarithromycin (Biaxin), and Ampicillin are often used in a short course of treatment.

The most commonly used antibiotic is metronidazole (Flagyl), usually given for four to eight weeks during flare-ups to induce remission (but not as a maintenance therapy). Flagyl also sometimes helps to heal fistulas. Flagyl produces annoying side effects such as a metallic taste and loss of appetite. No alcohol may be consumed when taking Flagyl.

Infliximab

In 1999, the federal Food and Drug Administration approved the use of Infliximab (trade name Remicade) in treating Crohn's disease. Infliximab is a chimeric monoclonal antibody-a manufactured protein designed to target a specific biological substance.

This medication is used for:

  • Disease that does not respond to standard treatments
  • Individuals who are unable to be weaned off of steroids successfully
  • Promoting healing of stubborn fistulas

Infliximab was engineered through the use of both mouse and human cells to act as both a carrier of chemicals called cytokines-proteins that regulate the immune response-and as an antagonist to tumor necrosis factor (TNF)-Alpha, meaning it reacts against TNF-Alpha. TNF-Alpha is a major component of the inflammatory process.

Two other anti-TNF medications are currently in clinical trials in individuals with Crohn's disease, as well as those who live with two other diseases generally thought to be autoimmune disorders, rheumatoid arthritis and lupus.

Experimental Treatments

Therapy with beneficial bacteria, called probiotics, are being examined both as way to replace toxic bacteria after antibiotic treatment and as a way to release protective chemicals into the body. Substances such as lactobacilli have shown promising results in animal studies, as well as in one small human study.

Small studies have shown that the medication Thalidomide, another anti-TNF agent, may be helpful in treating Crohn's disease that does not respond to other treatments. Any use of Thalidomide, however, would be controversial. Prescribed in Canada and Europe in the late 1950s and early 1960s as an anti-nausea medication for morning sickness during pregnancy, Thalidomide was taken off the market after because it caused severe, disfiguring birth defects.

Currently, Thalidomide is approved in the Unites States only for treatment of Hansen's disease (leprosy), and is the most tightly controlled drug on the market. A woman of childbearing age who accepts a prescription for Thalidomide must agree to use two forms of contraception, to have a monthly pregnancy test, and to undergo a therapeutic abortion if she becomes pregnant.

Alternative Treatments

A mind-body approach can help individuals with ulcerative colitis manage pain, and can contribute to both a sense of well-being and a feeling of control in a situation in which, in medical terms, they have little or no control.

  • Mind-body treatments include biofeedback, guided imagery, hypnotherapy, sound/music therapy, relaxation techniques, and prayer.
  • Postural therapies and exercises such as the Alexander technique, the Feldenkrais method, and the Trager method, as well as tai chi, which help an individual concentrate on choreographed body movements, are relaxing and provide a low-intensity physical workout when more active exercise is not possible.
  • Acupuncture and acupressure may also be beneficial.

Herbal treatments, naturopathic, and homeopathic treatments, however, are not recommended.

Need To Know:

It is important to note that there is no research evidence that these alternative therapies "undo" the cellular changes caused by ulcerative colitis. Therefore, mind-body therapy should always be used in conjunction with Western medicine, and not as a substitute for conventional medical treatments.

 

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From Andrew Maynard - Chair of the University of Michigan Department of Environmental Health Sciences, with help from David Faulkner - 2013 Master of Public Health graduate.