Treatment Options in IBD
If you have been diagnosed with Inflammatory Bowel Disease (IBD), you'll want to learn as much as possible about the treatment options available. Over the past decade, major advances in deciphering the mechanisms of this disease has greatly expanded those options. Understanding which forces are work—and when—have generated a number of exciting opportunities for therapeutic intervention.
Before 1990, only a few types of medication were available. Since then, there has been a dramatic increase both in the scope of research and in the development of medications to treat Crohn's disease and ulcerative colitis. As a result, people living with IBD have more treatment options than ever before. What's more, information emerging from ongoing clinical trials suggests that we can expect an even greater number of therapeutic choices in the years ahead.
The Aims of Medical Therapy
Currently, there are no medical cures for IBD. However, several different medications have proven to be effective in helping to control it. Medical therapy for IBD has three main goals:
- Inducing remission (periods of time that are symptom-free);
- Maintaining remission (preventing flare-ups of disease);
- Improving the patient's quality of life.
To achieve these goals, therapy must suppress the chronic intestinal inflammation that causes the symptoms of IBD. When the inflammation is under control, the intestines can absorb essential nutrients. This, in turn, enables patients to avoid surgery and long-term complications.
Types of Medications
Currently, there are five basic categories of medications used in the treatment of IBD: aminosalicylates, corticosteroids, immunomodulators, antibiotics, and biologic therapies.
Aminosalicylates are compounds that contain 5-aminosalicylic acid (5-ASA). These drugs, which can be given either orally or rectally, interfere with your body's ability to control inflammation. They are effective in treating mild-to-moderate episodes of ulcerative colitis and Crohn's disease, as well as preventing relapses and maintaining remission.
Corticosteroids were first introduced as therapy for IBD in the 1950s. Since that time, these powerful and fast-acting anti-inflammatory drugs have been the mainstay of treatment for acute flare-ups. Most patients notice an improvement in symptoms within days of starting corticosteroids. In addition to their anti-inflammatory action, corticosteroids also are immunosuppressive. That means they decrease the activity of the immune system, which experts believe may be out of control in people with IBD. As a result, they may make certain individuals more susceptible to catching infections.
Corticosteroids are recommended only for short-term use in order to achieve remission. As valuable as they are in acute situations, they are not effective in preventing flare-ups. As a result, they are rarely used for maintenance therapy in IBD. In addition, long-term use is not advised because of undesirable side effects. For that reason, corticosteroids are usually given in the lowest possible dosage for the shortest amount of time. Frequent short-duration use, however, is not recommended.
As their name implies, immunomodulators weaken or modulate the activity of the immune system. That, in turn, decreases the inflammatory response. Immunomodulators are most often used in organ transplantation to prevent rejection of the new organ, and in autoimmune diseases such as rheumatoid arthritis. Since the late 1960s, they have also been used to treat people living with IBD, which appears to be caused by an overactive immune system. These drugs are appropriate for those who:
- Do not respond to aminosalicylates, antibiotics, or corticosteroids;
- Have steroid-dependent disease or frequently require steroids;
- Have experienced side effects with corticosteroid treatment;
- Have perineal disease that does not respond to antibiotics;
- Have fistulas (abnormal channels between two loops of intestine, or between the intestine and another structure—such as the skin);
- Need to maintain remission.
An immunomodulator may be combined with a corticosteroid to speed up response during active flares of disease. Lower doses of the steroid are required in this case, producing fewer side effects. Corticosteroids also may be withdrawn more rapidly when combined with immunomodulators. For that reason, immunomodulators are sometimes referred to as "steroid-sparing" drugs.
Antibiotics are frequently used as a primary treatment approach in IBD, even though no specific infectious agent has been identified as the cause of these illnesses. However, researchers believe that antibiotics can help control symptoms of IBD by reducing intestinal bacteria and by directly suppressing the intestine's immune system.
They are also effective as long-term therapy in some people with IBD, particularly Crohn's disease patients who have fistulas (abnormal channels between two loops of intestine, or between the intestine and another structure—such as the skin) or recurrent abscesses (pockets of pus) near their anus. Patients whose active disease is successfully treated with antibiotics may be kept on these as maintenance therapy as long as the medications remain effective.
Although helpful in people with Crohn's disease, antibiotics generally are not considered useful for those with ulcerative colitis, either for maintaining remission or in acute situations. Clinical trials have not shown that antibiotics have value in treating severe ulcerative colitis. The exception is toxic megacolon, a condition that places people at high risk for perforation. This life-threatening complication is characterized by a distended abdomen and an extremely inflated colon.
The newest class of drugs to be used in IBD include Adalimumab (Humira®), Certolizumab pegol (Cimzia®), Infliximab (Remicade®), and Natalizumab (Tysabri®). Biologics are genetically engineered medications made from living organisms and their products, such as proteins, genes, and antibodies. Biologics interfere with the body's inflammatory response in IBD by targeting specific molecular players in the process such as cytokines—specialized proteins that play a role in increasing or decreasing inflammation. Promising targets include tumor necrosis factor (TNF)-alpha, interleukins, adhesion molecules, colony-stimulating factors, and others. Learning how these factors work has enabled researchers to design special treatment approaches that interrupt inflammation at various stages.
Biologic therapies offer a distinct advantage in IBD treatment. Their mechanism of action is targeted. Unlike corticosteroids, which tend to suppress the entire immune system and thereby produce major side effects, biologic agents act selectively. Therapies are targeted to particular enzymes and proteins that have already been proven defective, deficient, or excessive in people with IBD and in animal models of colitis.
Making the Right Selection
The ideal medication would be effective, safe, simple to administer, and affordable. It would also have few side effects. But the fact of the matter is that there is no single ideal therapy for IBD—treatment must be tailored to each person's needs.
A number of factors will determine which treatments are appropriate for you—including which part of your intestine is affected, the severity of your symptoms, and whether you are able to take certain drugs without experiencing undesirable side effects.
Finally, it's important to keep in mind that your therapeutic needs may change over time. What works at one point during your illness may not be effective during another stage. Clearly, it is important for you and your physician to discuss thoroughly which course of therapy is best for you—bearing in mind that a combination of therapies may well turn out to be the optimal treatment plan.
For further information, call CCFA at our Information Resource Center: 888.MY.GUT.PAIN (888.694.8872).
The Crohn’s & Colitis Foundation of America provides information for educational purposes only. We encourage you to review this educational material with your health care professional. The Foundation does not provide medical or other health care opinions or services. The inclusion of another organization’s resources or referral to another organization does not represent an endorsement of a particular individual, group, company or product.
About this resource
Published: May 30, 2012