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The goal of medical treatment in inflammatory bowel disease (IBD) is to suppress inflammation and induce mucosal healing.
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There are multiple different classes of medications that are effective in IBD, many of which can be used concomitantly.
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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.
Medical Therapy for Inflammatory Bowel Disease
Section snippets
Key points
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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Antioxidant and anti-inflammatory effects of hesperidin methyl chalcone in experimental ulcerative colitis
2021, Chemico-Biological InteractionsCitation Excerpt :The goal of medical treatment in IBD is to suppress inflammation and induce mucosal healing. The current treatment regimen includes salicylate (e.g., sulfasalazine, mesalamine), corticosteroids (i.g., cortisone and budesonide), immunomodulators (e.g., thiopurines and methotrexate), and biologic agents (e.g., infliximab, adalimumab) [7]. However, these drugs show several side effects, induce tolerance, and long-term use is limited due to high cost.
Modular design of a hybrid hydrogel for protease-triggered enhancement of drug delivery to regulate TNF-α production by pro-inflammatory macrophages
2020, Acta BiomaterialiaCitation Excerpt :This chronic condition is often encountered in many pathological conditions such as rheumatoid arthritis, chronic diabetic ulcers, inflammatory bowel diseases (IBDs), and chronic obstructive pulmonary diseases [1,3,7]. Systemic administration of anti-inflammatory therapeutics is a clinically accepted treatment paradigm to mitigate excessive inflammation in chronic diseases [1,8,9]. Small molecule drugs such as non-steroidal anti-inflammatory drugs (NSAIDs) and steroidal immuno-suppressants are empirically prescribed to patients with rheumatoid arthritis and IBDs based on their clinical symptoms [10–12].
Clinical Efficacy of Serum-Derived Bovine Immunoglobulin in Patients With Refractory Inflammatory Bowel Disease
2018, American Journal of the Medical SciencesCitation Excerpt :Since no current treatment for IBD is curative, the mainstay of current management of IBD is to control patient symptoms, avoid escalation of disease and improve quality of life.4 Treatment consists of anti-inflammatory, immunosuppressive, immune modulating and biologic agents.5 Despite therapy with multiple treatment modalities, many patients remain symptomatic.
Use of corticosteroids and immunosuppressive drugs in inflammatory bowel disease: Clinical practice guidelines of the Italian Group for the Study of Inflammatory Bowel Disease
2017, Digestive and Liver DiseaseCitation Excerpt :The two most common forms of IBDs are ulcerative colitis (UC), which affects only the colonic mucosa, and Crohn’s disease (CD), which can segmentally affects the entire digestive tract. UC and CD are autoimmune disorders that are not medically curable, although various medical therapies can control them [1]. The European Crohn’s and Colitis Organisation (ECCO) has prepared clinical practice guidelines on the diagnosis and management of CD [2] and UC [3].
The authors have nothing to disclose.