Treatment for Crohn's disease usually involves drug therapy or, in certain cases, surgery. There is currently no cure for the disease, and there is no one treatment that works for everyone. Doctors use one of two approaches to treatment — either "step-up," which starts with milder drugs first, or "top-down," which gives people stronger drugs earlier in the treatment process.
The goal of medical treatment is to reduce the inflammation that triggers your signs and symptoms. It is also to improve long-term prognosis by limiting complications. In the best cases, this may lead not only to symptom relief but also to long-term remission.
Anti-inflammatory drugs are often the first step in the treatment of inflammatory bowel disease. They include:
- Oral 5-aminosalicylates. These drugs may be helpful if Crohn's disease affects your colon, but they aren't helpful treating disease in the small intestine. They include sulfasalazine (Azulfidine), which contains sulfa, and mesalamine (Asacol, Delzicol, Pentasa, Lialda, Apriso). These drugs, especially sulfasalazine, have a number of side effects, including nausea, diarrhea, vomiting, heartburn and headache. These drugs have been widely used in the past but now are generally considered of limited benefit.
Corticosteroids. Corticosteroids such as prednisone can help reduce inflammation anywhere in your body, but they have numerous side effects, including a puffy face, excessive facial hair, night sweats, insomnia and hyperactivity. More-serious side effects include high blood pressure, diabetes, osteoporosis, bone fractures, cataracts, glaucoma and increased chance of infection.
Also, corticosteroids don't work for everyone with Crohn's disease. Doctors generally use them only if you don't respond to other treatments. A newer type of corticosteroid, budesonide (Entocort EC), works faster than do traditional steroids and appears to produce fewer side effects. However, it is only effective for Crohn's disease that's in certain parts of the bowel.
Corticosteroids aren't for long-term use. But they can be used for short-term (three to four months) symptom improvement and to induce remission. Corticosteroids may also be used with an immune system suppressor — the corticosteroids can induce remission, while the immune system suppressors can help maintain it.
Immune system suppressors
These drugs also reduce inflammation, but they target your immune system, which produces the substances that cause inflammation. For some people, a combination of these drugs works better than one drug alone. Immunosuppressant drugs include:
Azathioprine (Imuran) and mercaptopurine (Purinethol). These are the most widely used immunosuppressants for treatment of inflammatory bowel disease. Taking them requires that you follow up closely with your doctor and have your blood checked regularly to look for side effects, such as a lowered resistance to infection.
Short term, they also can be associated with inflammation of the liver or pancreas and bone marrow suppression. Long term, although rarely, they are associated with certain infections and cancers including lymphoma and skin cancer. They may also cause nausea and vomiting. Your doctor will use a blood test to determine whether you can take these medications.
Infliximab (Remicade), adalimumab (Humira) and certolizumab pegol (Cimzia). These drugs, called TNF inhibitors or “biologics,” work by neutralizing an immune system protein known as tumor necrosis factor (TNF). They are used for adults and children with moderate to severe Crohn's disease to reduce signs and symptoms. They also may induce remission. Researchers continue to study these drugs to compare their benefits.
TNF inhibitors may be used soon after diagnosis, particularly if your doctor suspects that you're likely to have more severe Crohn's disease or if you have a fistula. Sometimes they are used after other drugs have failed. They also may be combined with an immunosuppressant in some people, but this practice is somewhat controversial.
People with certain conditions can't take TNF inhibitors. Tuberculosis and other serious infections have been associated with the use of immune-suppressing drugs. Talk to your doctor about your potential risks and have a skin test for tuberculosis, a chest X-ray and a test for hepatitis B before starting these medications. They are also associated with certain cancers, including lymphoma and skin cancers.
Methotrexate (Rheumatrex). This drug, which is used to treat cancer, psoriasis and rheumatoid arthritis, is sometimes used for people with Crohn's disease who don't respond well to other medications.
Short-term side effects include nausea, fatigue and diarrhea, and rarely, it can cause potentially life-threatening pneumonia. Long-term use can lead to bone marrow suppression, scarring of the liver and sometimes to cancer. You will need to be followed closely for side effects.
- Cyclosporine (Gengraf, Neoral, Sandimmune) and tacrolimus (Astagraf XL, Hecoria). These potent drugs, often used to help heal Crohn's-related fistulas, are normally reserved for people who haven't responded well to other medications. Cyclosporine has the potential for serious side effects, such as kidney and liver damage, seizures, and fatal infections. These medications aren't for long-term use.
Natalizumab (Tysabri) and vedolizumab (Entyvio). These drugs work by stopping certain immune cell molecules — integrins — from binding to other cells in your intestinal lining. Natalizumab is approved for people with moderate to severe Crohn's disease with evidence of inflammation who aren't responding well to any other medications.
Because the drug is associated with a rare but serious risk of progressive multifocal leukoencephalopathy — a brain disease that usually leads to death or severe disability — you must be enrolled in a special restricted distribution program to use it.
Vedolizumab recently was approved for Crohn's disease. It works like natalizumab but appears not to carry a risk of brain disease.
- Ustekinumab (Stelara). This drug is used to treat psoriasis. Studies have shown it's useful in treating Crohn's disease as well and may be used when other medical treatments fail.
Antibiotics can reduce the amount of drainage and sometimes heal fistulas and abscesses in people with Crohn's disease. Some researchers also think antibiotics help reduce harmful intestinal bacteria that may play a role in activating the intestinal immune system, leading to inflammation.
Antibiotics may be used in addition to other medications or when infection is a concern, such as with perianal Crohn's disease. However, there's no strong evidence that antibiotics are effective for Crohn's disease. Frequently prescribed antibiotics include:
- Metronidazole (Flagyl). At one time, metronidazole was the most commonly used antibiotic for Crohn's disease. However, it can cause serious side effects, including numbness and tingling in your hands and feet and, occasionally, muscle pain or weakness. If these effects occur, stop the medication and call your doctor.
- Ciprofloxacin (Cipro). This drug, which improves symptoms in some people with Crohn's disease, is now generally preferred to metronidazole. A rare side effect is tendon rupture, which is an increased risk if you're also taking corticosteroids.
In addition to controlling inflammation, some medications may help relieve your signs and symptoms, but always talk to your doctor before taking any over-the-counter medications. Depending on the severity of your Crohn's disease, your doctor may recommend one or more of the following:
- Anti-diarrheals. A fiber supplement, such as psyllium powder (Metamucil) or methylcellulose (Citrucel), can help relieve mild to moderate diarrhea by adding bulk to your stool. For more severe diarrhea, loperamide (Imodium) may be effective. Anti-diarrheals should only be used after discussion with your doctor.
- Pain relievers. For mild pain, your doctor may recommend acetaminophen (Tylenol, others) — but not other common pain relievers, such as ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve, Anaprox). These drugs are likely to make your symptoms worse, and can make your disease worse as well.
- Iron supplements. If you have chronic intestinal bleeding, you may develop iron deficiency anemia and need to take iron supplements.
- Vitamin B-12 shots. Crohn's disease can cause Vitamin B-12 deficiency. Vitamin B-12 helps prevent anemia, promotes normal growth and development, and is essential for proper nerve function.
- Calcium and vitamin D supplements. Crohn's disease and steroids used to treat it can increase your risk of osteoporosis, so you may need to take a calcium supplement with added vitamin D.
Your doctor may recommend a special diet given via a feeding tube (enteral nutrition) or nutrients injected into a vein (parenteral nutrition) to treat your Crohn's disease. This can improve your overall nutrition and allow the bowel to rest. Bowel rest can reduce inflammation in the short term.
Your doctor may use nutrition therapy short term and combine it with medications, such as immune system suppressors. Enteral and parenteral nutrition are typically used to get people healthier prior to surgery or when other medications fail to control symptoms.
Your doctor may also recommend a low residue or low-fiber diet to reduce the risk of intestinal blockage if you have a narrowed bowel (stricture). A low residue diet is designed to reduce the size and number of your stools.
If diet and lifestyle changes, drug therapy or other treatments don't relieve your signs and symptoms, your doctor may recommend surgery. Up to one-half of individuals with Crohn's disease will require at least one surgery. However, surgery does not cure Crohn's disease.
During surgery, your surgeon removes a damaged portion of your digestive tract and then reconnects the healthy sections. Surgery may also be used to close fistulas and drain abscesses. A common procedure for Crohn's disease is strictureplasty, which widens a segment of the intestine that has become too narrow.
The benefits of surgery for Crohn's disease are usually temporary. The disease often recurs, frequently near the reconnected tissue. The best approach is to follow surgery with medication to minimize the risk of recurrence.
Aug. 14, 2014
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