Traditional Treatment of Crohn’s Disease
The goal of the traditional treatment of Crohn’s Disease is to (1) induce remission, (2) maintain remission for the longest period of time and (3) reduce the frequency, duration and severity of flares. While the goal of this site is to provide information about alternatives to these traditional Crohn’s disease treatments, an explanation of the most frequently prescribed Crohn’s disease treatment options is still helpful.
There is no best treatment for Crohn’s disease, and Crohn’s disease treatment guidelines are difficult for the average patient to find. A doctor or other healthcare provider commonly treats Crohn’s disease with one of the three following methods:
- bowel rest
Which treatment a person needs depends on the severity of the disease and symptoms. The symptoms and complications can vary widely based on factors unique to each patient. Since each person experiences the disease differently, health care providers adjust the Crohn’s disease treatment options to improve the person’s symptoms and induce remission. The best medication for Crohn’s disease for one person may not work in another.
Clinical remission is where the symptoms of the disease lessen significantly or disappear altogether. Until there is a definitive cure, clinical remission is generally what a doctor attempts to achieve for Crohn’s disease patients. Alternate kinds of remission in Crohn’s disease could include Biological Remission, where blood and fecal markers return to normal values or Endoscopic Remission, where there is mucosal healing that can be seen when the lining of the affected area is biopsied. Between periods of remission, there are times of active disease, or flares. Traditional medications for Crohn’s disease aim to lengthen the periods of remission and decrease flares.
While no traditional medication cures Crohn’s disease, many can reduce symptoms. Most Crohn’s disease patients will require medication to control their illness. The goals of medication therapy are inducing and maintaining remission and improving the patient’s quality of life. These treatments seek to control the inflammation caused by Crohn’s disease once it has begun, rather than treating the root cause of Crohn’s disease, which is a subject of much debate. The traditional Crohn’s disease medications can be broken down into five categories, described in more detail below:
- Biologic therapies
- Other medications
General Information About Aminosalicylates
An aminosalicylate is a medication that contains 5-aminosalicyclic acid (5-ASA), which helps control inflammation and is a relative of aspirin. Health care providers have been using aminosalicylates to treat people newly diagnosed with mild Crohn’s disease for 30 years, though it has shown more effective in ulcerative colitis. The latest information shows that aminosalicylates are more helpful in treating Crohn’s disease of the colon, but not that of the small intestine. Because of this, they are considered to be of limited benefit in Crohn’s disease. Aminosalicylates are localized to the bowel lining, although the mechanism by which they work to reduce inflammation is unclear. It is thought that they may work to decrease the release of inflammatory chemicals produced by the gut. Some preparations are time released in an attempt to target specific portions of the bowel. Examples of aminosalicylates, with the generic name shown prior to the capitalized brand name(s), include:
- balsalazide (Colazal, Giazo)
- mesalamine (Asacol, Canasa, Pentasa, Rowasa, Delzicol, Lialda, Apriso, Salofalk)
- olsalazine (Dipentum)
- sulfasalazine which is a combination of sulfapyridine and 5-ASA (Azulfidine)
- Aminosalicylates are either taken by mouth or as a rectal suppository or enema. Generally, they must be taken for a long period of time to realize a benefit, Those with a sulfa allergy may not be able to tolerate sulfasalazine. Some of the common side effects of aminosalicylates include:
- abdominal pain
- nausea and vomiting
- skin sensitivity
- Rarely, complications such as bone marrow suppression, heart problems, allergic reactions or kidney and liver damage can occur.
General Information About Corticosteroids
Corticosteroids, also known as steroids, help reduce the activity of the immune system and decrease inflammation. Introduced in the 1950’s, they are one of the oldest treatments for Crohn’s disease. In addition to Crohn’s disease, they are used to treat many other conditions such as lupus, rheumatoid arthritis, multiple sclerosis, asthma, Addison’s disease, allergies and skin conditions. Not to be confused with body-building (anabolic) steroids, corticosteroids are synthetic medications, and work by mimicking the effects of the hormones produced naturally by the adrenal glands to suppress the immune system. Because this therapy is usually systemic, and not localized to a specific region, side effects of corticosteroids can be more severe. However, newer formulations like budesonide are localized to the small intestine. Health care providers prescribe corticosteroids for people with moderate to severe Crohn’s disease symptoms. A list of common corticosteroids include:
- budesonide (Entocort, UCERIS, Pulmicort)
- hydrocortisone (Cortef, Cortenema, Proctofoam)
- methylprednisolone (Medrol)
- prednisone (Deltasone)
- prednisolone (Orapred)
In Crohn’s disease, corticosteroids are usually taken my mouth, but can be given rectally, intravenously or topically. Corticosteroids are powerful, fast acting medications. They effectively induce remission for many patients, but between 20-30% will not respond to treatment with corticosteroids. Due to the potential side effects, they are generally taken for short periods of time to achieve remission or control severe symptoms where other medications have failed. They can be used in combination with some other Crohn’s disease treatments in an attempt to induce and retain remission. When taken for less than a month or at lower doses, troublesome side effects are unlikely, but can increase in severity when taken for longer periods of time. Side effects of corticosteroids include:
- rounding of the face (“moon face”)
- a higher chance of developing infections
- bone mass loss
- high blood glucose
- high blood pressure
- mood swings, restlessness or nervousness
- weight gain
- increased facial hair
- stretch marks
- psychiatric symptoms
- reduced growth in children
Corticosteroids cannot be stopped abruptly, but must be reduced gradually, tapering to lower doses over time. This allows the adrenal glands to begin producing its natural hormones once again. Some patients may become steroid dependant to remain in remission, or experience a flare upon tapering to a lower dose.
General Information about Immunomodulators
Immunomodulators reduce or change immune system activity, which optimally results in less inflammation in the GI tract and alleviates the symptoms of Crohn’s disease. They generally work by altering the creation and function of DNA by competing with purine derivatives. (Purine derivatives are organic compounds that are part of DNA.) Their use in Crohn’s disease began in the late 1960’s, but they are commonly used to prevent organ transplant rejection and to treat rheumatoid arthritis and cancer. Immunomodulators are used when other treatments have failed. They are most effective at maintaining remission or treating fistulas. These medications can take several weeks to 6 months to start working, and are sometimes effective to wean a steroid dependent patient, which is termed “steroid-sparing.” Immunomodulators include:
- mercaptopurine or 6-MP (Purinethol)
- azathioprine (Imuran, Azasan)
- cyclosporine (Sandimmune, Neoral, Gengraf)
- tacrolimus (Prograf)
- methotrexate (MTX, Mexate, Rheumatrex, Trexall)
Immunomodulators are generally taken by mouth, but in some case are injected, given intravenously or applied topically. People taking these medications may have the following side effects:
- Side effects of Azathioprine and Mercaptopurine: nausea, vomiting, diarrhea, skin irritation or rash, headache, dizziness, abdominal pain, or generally feeling ill. Rare, more serious side effects include a low white blood cell count, which can lead to a higher chance of infection or serious bleeding, pancreatitis, hair loss, problems with urination, mouth sores or black/bloody stools.
- Side effects of Methotrexate: nausea, vomiting, fatigue, diarrhea, headache, low white blood cell count which predisposes the patient to infection. Rare, more serious side effects include liver damage, kidney failure, central nervous system damage, neurological damage, memory and skin issues. Methotrexate impairs folic acid and should not be taken during pregnancy.
- Side effects of Cyclosporine and Tacrolimus: headaches, sleep disturbance, a risk of infection, decreased kidney and liver function, diabetes, leg cramps, mild tremors, increased facial hair, ulcers, elevated blood pressure, neuropsychiatric problems, and risk of lymphoma. While these are faster-acting medications, they carry increased risks of side effects.
Health care providers most often prescribe cyclosporine only to people with severe Crohn’s disease because of the medication’s serious side effects.
General Information About Biologic Therapies
Biologic therapies have been in use since the late 1990’s and are used in moderate to severe Crohn’s disease cases where other therapies have failed. Some practitioners prefer to use biologics as a first line therapy to attempt to alter the disease progression at the outset. They are medications that target specific proteins made by the immune system in the inflammatory cascade, these are also used in rheumatoid arthritis, multiple sclerosis, and lupus. The goal of biologic therapies is to interrupt the chain reaction causing inflammation, and, therefore, decrease inflammation in the intestine.
Humira, Remicade, Simponi and Cimzia all target the protein TNF-alpha. Tysabri inhibits alpha-4 integrin, which inhibits the ability of inflammatory immune cells from crossing into the intestine. Similar to Tysabri, Entyvio, which is more effective in ulcerative colitis, inhibits alpha-4-beta-7 integrin to inhibit the ability of inflammatory immune cells from crossing into the intestine. Biologic therapies work more quickly than immunomodulators to lessen symptoms and achieve remission, possibly as quickly as 2 weeks, though for some it may take longer to gain relief from symptoms. Biologic therapies include:
- adalimumab (Humira)
- certolizumab (Cimzia)
- infliximab (Remicade)
- natalizumab (Tysabri)
- vedolizumab (Entyvio)
- golimumab (Simponi)
These medications are either injectable or administered as an intravenous infusion by a heath care provider. For intravenously administered medications, patients receive an infusion every 4 to 8 weeks. If the medication is received via an injection, patients learn to inject themselves every 1-4 weeks at home. These therapies usually begin with a higher, more frequent dosage schedule to establish a clinical level of the drug. Once on a biologic therapy, the patient remains on the medication until it loses effectiveness. Stopping and restarting usually renders the therapy ineffective. While biologics target only a particular portion of the immune cascade, they act systemically towards that portion. Side effects of biologic treatments may include:
- pain, redness or irritation at the injection/infusion site
- fever or chills
- impaired breathing
- low blood pressure
- stomach or back pain
- a toxic reaction to the medication
- a higher chance of developing infections, particularly tuberculosis.
In rare cases, a serious infection or sepsis could occur. Patients with latent tuberculosis risk reactivating their disease. Biologics have made cases of heart failure worse. There have also been cases of blood and nervous system disorders, including lymphoma. An increased risk of developing a rare brain infection, PML, has been associated with natalizumab (Tysabri), which may also cause liver damage.
Recently Biosimilar medications have begun to be approved for us in Crohn’s disease. A biosimilar drug is a medication which is highly similar to a previously approved FDA biologic medication. Biosimilars have no clinical meaningful differences in terms of safety and effectiveness from their patented counterparts. For more information, please see the article about Biosimilar Medications in Crohn’s Disease.
Other medications to treat symptoms or complications of Crohn’s disease may include:
- Antibiotics, such as ciprofloxacin (Cipro) and metronidazole (Flagyl), are used to prevent or treat infections, abscesses, and fistulas.
- Anti-Diarrheal Medications, such as loperamide (Imodium) help slow or stop severe diarrhea by decreasing intestinal movement. These medications should be taken for short periods of time since there is a risk of developing toxic megacolon.
- Cholestyramine (Prevalite, Questran), which comes in powder form, is used to treat diarrhea by removing bile acids from the body. Generally used to treat high cholesterol, it is used for Crohn’s patients who have had their terminal ileum removed. Since bile acids are absorbed in this region, it’s absence allows bile acids to pass into the colon, resulting in diarrhea. Cholestyramine inactivates the bile acids prior to their arrival in the colon.
Sometimes Crohn’s disease symptoms are so severe that a person may need to spend a period of time on bowel rest. This can last for a few days to months in the most severe cases. Bowel rest involves drinking only clear liquids or having no oral intake. Enteral nutrition is where the patient receives their nutrition through a feeding tube. Parenteral nutrition is where the nutrients are given directly into a vein and is more common when the patient has an abscess, fistula, obstruction or undergoes surgery. During bowel rest, some patients stay in the hospital while other patients are able to receive the treatment at home. In some cases, the intestines are able to heal during bowel rest, but bowel rest is not without controversy.
Even with medication, the majority of patients with Crohn’s disease will require surgery at some point during their lives. Surgery becomes necessary in Crohn’s disease when medications can no longer control the symptoms. Nearly 80% of Crohn’s patients will eventually require surgery to treat their disease, and of those, about 60% will have a recurrence of their disease within 10 years of surgery. Because of this and the risks associated with all surgery, it is avoided until other viable options have been exhausted. Although surgery will not cure Crohn’s disease, it can treat complications and improve symptoms for a period of time. Talk to you doctor about the benefits and risks associated with bowel surgery. Surgery is generally recommend to treat:
- fistulas or a hole in your bowel
- bleeding that is life threatening
- bowel obstructions
- side effects from medications that severely threaten a person’s health
- symptoms which are not improved by medication
- The most widely used types of operations to treat Crohn’s disease are:
- small bowel resection
- subtotal colectomy
- proctocolectomy and ileostomy
Patients will receive general anesthesia. Most patients will stay in the hospital for 3 to 7 days after the surgery. Full recovery may take 4 to 6 weeks.
An intestinal stricture/stenosis is a narrowed portion of the intestine caused by long-term inflammation or scarring. Strictures are common in Crohn’s disease and can cause a partial or full bowel obstruction if severe. For severe strictures that do not respond to medication, a doctor may recommend an operation. A stricturoplasty, or strictureplasty, is an operation where a small cut is made at the stricture location and the intestine is repaired in a way to correct the narrowing effect. It does not involve removing portions of the intestine. For this reason, it is advantageous over more invasive surgery and recovery time is shortened.
Small bowel resection
Small bowel resection is surgery to remove part of a patient’s small intestine. When a patient with Crohn’s disease has a blockage or severe disease in the small intestine, a surgeon may need to remove that section of small intestine. A small bowel resection can sometimes be performed laparoscopically, where the surgeon will make several small, half-inch incisions in the patient’s abdomen in order to access the affected area. A tiny camera is used to give the surgeon a close-up view of the small intestine. The surgical instruments are inserted through the small incisions in order to remove the diseased or blocked section of small intestine. The ends of the intestine are then reconnected. Because laparoscopy is less invasive, it generally results in less scarring, complications and pain, and has a shorter recovery time.
Alternatively, the resection may be done through open surgery, where one incision about 6 inches long is made in the patient’s abdomen. The diseased section of small intestine is then removed and the small intestine repaired. Sometimes a temporary ileostomy, or bypass, is required to allow the damaged portion of small intestine to fully heal. Once the intestine has healed, the bowel can be reconnected and the ileostomy reversed. For a more detailed description of an ileostomy, see below.
A subtotal colectomy also called a large bowel resection, is surgery to remove part of a patient’s large intestine (colon). When a patient with Crohn’s disease has a blockage, a fistula, or severe disease in the large intestine, a surgeon may need to remove that section of intestine. As in the small bowel resection above, a subtotal colectomy can be performed laparoscopically or by open surgery and involves a similar procedure, but is performed on the colon.
Proctocolectomy, colectomy, and ileostomy
In a proctocolectomy, a patient’s entire colon and rectum are removed. A colectomy is where the colon is removed, but the rectum is left intact. After a proctocolectomy or a colectomy, waste cannot leave the body through the normal route, so an ileostomy (stoma) is necessary. The surgeon will create an opening in the abdomen, and will bring the unattached end of the small intestine (the ileum) through this opening. It is then attached to the skin to create an opening of an inch or two outside of the patient’s body, usually in the lower abdomen.
A removable external collection pouch/bag connects to the stoma by adhering to the abdominal skin and collects waste outside the patient’s body. Intestinal contents pass through the stoma instead of passing through the anus. The bag is hidden under clothing and eventually does not restrict normal activity. People who have this type of surgery will have the ileostomy for the rest of their lives, and it is only done in cases where damage or the disease cannot be treated by a less invasive method.
While the goal of traditional Crohn’s disease treatments is to manage the patient’s symptoms, induce and maintain remission, there is not a single treatment available that will work for all Crohn’s disease sufferers. With the right medical care, Crohn’s disease can be managed to provide the patient with a good quality of life. In addition to the above treatments, there are many new and emerging Crohn’s disease treatments on the horizon that give hope to people everywhere. We invite you to continue browsing this site to read more about these emerging therapies and discuss them with your doctor.