Medical Therapy for Inflammatory Bowel Disease

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Key points

  • The goal of medical treatment in inflammatory bowel disease (IBD) is to suppress inflammation and induce mucosal healing.

  • There are multiple different classes of medications that are effective in IBD, many of which can be used concomitantly.

  • The perioperative medical management of IBD can be challenging, and physicians must weigh the possible increased risk of surgical complications versus the potential for recurrent disease without appropriate therapy.

5-Aminosalicyclic Acid Compounds

5-ASA compounds are a class of medication used for the induction and maintenance of remission in patients with IBD. They have been the traditional first-line therapy in the treatment of mild to moderate ulcerative colitis (UC); efficacy in Crohn's disease (CD) remains controversial.

Immunomodulator therapy

Thiopurines and methotrexate are commonly used immunomodulator therapies. Cyclosporine has a role in fulminant colitis.

Actions and characteristics

Infliximab, adalimumab, golimumab, and certolizumab pegol are biologic agents that target TNF activity, decreasing mucosal inflammation through multiple mechanisms. Infliximab is a chimeric immunoglobulin (Ig) G1 antibody that binds to TNF, and in the late 1990s, it was the first biologic approved for use in IBD. It is administered intravenously. Adalimumab and golimumab are humanized IgG1 antibodies that bind to TNF and are administered subcutaneously. Certolizumab pegol is a pegylated Fab

Actions and Characteristics

Corticosteroids, like many of the other drugs used in the treatment of IBD, were first developed to treat rheumatoid arthritis. Corticosteroids work by inhibiting almost every aspect of the immune response. They inhibit expression of adhesion molecules and trafficking of inflammatory cells of all target tissues, including the intestines. They also induce apoptosis of activated lymphocytes and decrease expression of inflammatory cytokines.77, 78, 79, 80, 81 As early as 1954, an RCT demonstrated

Fistulizing Crohn's disease

The transmural inflammatory nature of CD predisposes to the formation of fistulae, a complication indicating a more aggressive and refractory disease phenotype.99 Neither oral nor topical 5-ASA compounds have any utility in the treatment of fistulizing CD. Antibiotics (most commonly ciprofloxacin and metronidazole) have commonly been used in the treatment of enterocutaneous and perianal fistulae and are often effective at improving symptoms.100, 101 However, there are no placebo-controlled

Fulminant colitis

Fulminant colitis secondary to IBD is a clinical scenario in which the surgeon should be intimately involved. It is more commonly described in UC, but can occur in CD as well. Despite the complexities and challenges that these patients present, the approach is simple: aggressive medical management, and early surgery in nonresponders.112

The cornerstone of initial therapy is intravenous corticosteroids with a dose equivalent to 60 mg methylprednisolone daily (which can be given either as a

Perioperative considerations

Despite advances in medical management, surgical intervention is still necessary in many patients with IBD. The operative management of CD is generally reserved for patients who have an obstructing fibrotic stricture, perforation, cancer, or fistulae or active luminal inflammation refractory to medical management. Indications for surgery in UC include fulminant colitis, dysplasia, neoplasia, medically intractable disease, and patient preference. The perioperative medical management of IBD has

Postoperative recurrence of Crohn's disease

Greater than 75% of patients diagnosed with CD will eventually require surgical intervention.143 Unfortunately, recurrence is very common. After ileal or ileocolonic resection, there is a 20% to 30% symptomatic recurrence rate in the first year after surgery, with a 10% increase each subsequent year. Most patients will eventually suffer recurrence, and a reoperation rate of 50% to 60% is generally reported.144 Most evidence-based assessments of postoperative CD to date have focused on symptom

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