Treatment for IBD
Once you have been diagnosed with Crohn’s disease or ulcerative colitis, your healthcare team will put a treatment plan in place. The aim of this plan is to induce remission. One remission is achieved the plan is to maintain remission. You will usually maintain a close relationship with your healthcare team over the course of your treatment.
Induce remission - 'get well' - Your healthcare team will prescribe the best treatment for you to heal the inflammation that is causing your symptoms. This will provide relief from your symptoms and allow you to get back to doing the things that you like. Remission can be achieved in most cases and can last for anything from weeks to years. No two cases are the same and no one treatment will work for everyone. You cannot therefore predict the course of your disease, nor can you compare your treatment or outcome to that of another person.
Maintain remission - 'stay well' - Once your disease goes into remission, your healthcare team will prescribe the best treatment to ensure that the inflammation does not recur. This may or may not be the same treatment which was used to induce remission. During remission you should experience little or no symptoms and you should be able to eat a normal diet and enjoy life to the full. It is not unusual for your healthcare team to change your treatments based on a number of factors, for example your reported symptoms or the results of blood tests of scans.
There are a number of different treatments for IBD
- Drug therapy
- Dietary management of symptoms
- Medication to manage symptoms
Drug therapy is usually the first line of therapy. Doctors have many different drugs to choose from. All drugs that are used in the management of IBD have a proven track record in inducing remission but do not necessarily work for everyone.
We do not attempt to provide everything there is to know about each drug as it would be impossible for this to be always reliable and up to date. Instead we recommend that you educate yourself about the particular drug or drugs that have been prescribed for you.
Aminosalicylates are anti-inflammatory drugs that contain 5-aminosalicylic acid. They are used as a first-line treatment for mild to moderate ulcerative colitis, and mild Crohn’s disease. Some examples of the most commonly used aminosalicylate preparations prescribed in Ireland are Sulfasalazine (Salazopyrin), Mesalazine (Asacolon, Pentasa, Mezavant XL, Salofalk), Olsalazine (Dipentum). They are used for treating flares of IBD to induce remission, or for the maintenance of remission. You should normally expect these drugs to take effect in four to eight weeks from starting the course. They can be given in tablet, suppository or enema form.
These are rapid acting anti-inflammatory drugs. They are often used to treat moderate to severe Crohn’s disease or ulcerative colitis. Some examples of corticosteroids in use in Ireland are Prednisolone, Budesonide (Budenofalk, Entocort, Budesonide), Methylprednisolone (Medrone), and Hydrocortisone. Steroids can have a wide range of side effects and they suppress the immune system. You may be started on a high dose of steroids but this will reduce gradually until the course finishes. They are usually only used to induce remission. If steroids are successful in inducing remission, doctors will normally prescribe other drugs to maintain remission. You should normally expect steroids to take effect in one to three weeks from starting the course. It is important to take a calcium supplement when taking steroids as they can cause bone weakening, these should be prescribed by the doctor prescribing steroids.
These drugs have the effect of suppressing the immune system. For this reason you may hear them being referred to as 'immunosuppressive' drugs. They are used if you have not had a satisfactory response to, or cannot tolerate other drugs. They can also be used if you become steroid dependant i.e. your disease can only be controlled with steroids. For this reason you may also hear these drugs being referred to as 'steroid sparing' drugs. In Crohn's disease immunomodulators can be used to prevent a recurrence of the disease after surgery and can be used to treat fistulae and abscesses. Examples of immunomodulator drugs in use in Ireland for IBD include 6-Mercaptopurine/6-MP (Purinethol), Azathioprine (Imuran), Methotrexate and Ciclosporin. If you have been prescribed an immunomodulator it is very important to learn about your particular drug, its side effects and interactions with other substances. You may have to have your bloods checked regularly. You should also be aware that you may be more susceptible to infection and you should take precautions to avoid risks wherever possible. If you do get an infection you should get it treated early. These drugs can take time to take effect, sometimes up to four months. Steroids are often used in conjunction with immunomodulators to induce remission whilst you are waiting for the immunomodulators to take effect.
Biologic therapies (anti-TNF drugs)
These drugs emerged in the late 1990s. TNF is a molecule which is known to have a role in the inflammatory response. These drugs have the effect of blocking TNF and are therefore also referred to as anti-TNF drugs. Unlike other drugs their effect can last several weeks in the body. They are administered either by intravenous infusion in hospital or self-administered injection at home. They are used to treat moderate to severe disease.
- Remicade (Infliximab) is administered in hospital by intravenous infusion, usually every eight weeks. The first doses are administered at weeks 0, 2, 6, moving to a regular eight-weekly cycle if the drug is effective.
- Adalimumab (Humira) is administered by the patient or a family member at home, with training from a specialised nurse. If you are prescribed this drug you will be given support and shown how to administer the drug.
Antibiotics are sometimes used to treat some of the complications associated with Crohn's. They can be used to treat fistulae and abscesses which can arise with Crohn's disease, particularly in the perianal area.
Dietary management of symptoms
If you are experiencing a lot of symptoms such as abdominal pain/cramping and/or diarrhoea, switch to a bland diet until you are well enough to return to a normal diet:
- cut out fatty/greasy foods - these are difficult to digest even when we're well
- you may be temporarily lactose intolerant during a flare, so try lactose-free products or switch to dairy-free alternatives
- eat smaller meals (6-8 small meals per day) but more regularly, and really chew your food - your digestive system is not working at its best during a flare so by eating small meals it's easier for your digestive system to cope
- when you start to feel better again you can introduce some of the regular things back into your diet, gradually at first, until you can eat your normal diet again
If these self-management tips don't work, ask for a referral to a dietitian to discuss your own dietary and nutritional needs.
It is important to be aware that whilst dietary management of symptoms can play an important role in managing symptoms and maintaining good nutrition, it does not actually treat the underling inflammation. This is the role of drug therapy.
Medication to manage symptoms
If you are experiencing symptoms such as diarrhoea, spasm/cramp, extreme fatigue etc, talk to your GP or pharmacist about medication to control this. Combined with a change to your diet many people find that they can make a big difference to the impact of these debilitating symptoms.
Advances in surgery have resulted in much safer procedures, less pain and scarring, shorter hospital stays and shorter postoperative recovery times. Advances in minimal access surgery mean that many procedures are performed using 'keyhole' surgery for Crohn’s disease and ulcerative colitis. The use of Enhanced Recovery Programmes mean that hospital stays are shorter.
Surgery in Crohn’s disease
Emphasis will be placed on preserving as much healthy bowel as possible. Surgical procedures may be required in Crohn's disease to:
- Repair fistulae or drain abscesses
- Bowel resection - this involves removing a diseased area of bowel
- Stricturoplasty - this involves releasing strictures (narrowed sections of bowel caused by repeated inflammation and build up of scar tissue) without the need for a bowel resection
Surgery in ulcerative colitis
In severe cases of ulcerative colitis, the patient is cured by the surgical removal of the entire colon. Although this sounds like quite a drastic procedure, it is only considered in severe cases of ulcerative colitis and the patient usually has an immediate improvement in quality of life. Surgical removal of the colon is usually followed by an ileostomy. You will be given lots of support from a stoma care nurse and/or IBD nurse specialist if this is the case. In some cases this need only be temporary and can be reversed by forming a pouch which serves as a rectum so that you can return to going to the bathroom as normal.