How is Crohn’s disease treated?

For Crohn’s disease to be treated effectively, the treatment plan will typically involve drug therapy, and in some more severe cases, surgery will be required. Crohn’s disease does not have a cure and more research on the condition is needed in order for researchers to possibly find one. There is no method of treatment that works the same for everyone. Doctors tend to use either a step-up form of treatment which starts the patient on the milder drugs first and then increases dosages or changes the type of medication prescribed over time, or a top-down form of treatment which starts the patient on the stronger drugs during the initial stages of treatment and then tapers the dosage or type of medication off over time.  

The treatment of Crohn’s disease aims to reduce the inflammation that triggers a patient’s symptoms. The treatment will also attempt to improve the long-term complications and prognosis. The most that a patient can hope for is that they are able to go into long term remission.

Anti-inflammatory drugs

These types of drugs are typically the first option of treatment for patients with IBD (inflammatory bowel disease). These drugs include:

Oral 5-aminosalicylates – These are often used when Crohn’s affects the colon, they are not effective when used in treating the disease if it has affected the small intestine. These drugs have several side effects and have recently been considered to have only a limited benefit. Some of their side effects are diarrhoea, headaches, nausea, vomiting and heartburn. Oral 5-aminosalicylates include:

• Mesalamine - Delzicol, Asacol, Lialda, Pentasa, Apriso
• Sulfasalazine (contains sulfa) - Azulfidine

Corticosteroids – These include the drug known as prednisone, and can help in reducing inflammation in any area of the patient’s body. These also have a number of side effects which include:

• Night sweats
• Puffy face
• Insomnia
• Excessive facial hair
• Hyperactivity

More serious side effects include:

• Cataracts
• Diabetes
• Osteoporosis
• Bone fractures
• Increased chances of infection

These drugs do not seem to work for every patient who has been diagnosed with Crohn’s disease. They are normally prescribed when the patient does not respond to other means of treatment. There is a new kind of corticosteroid known as budesonide (Entocort EC), this tends to work faster when compared to the more traditional steroids. This drug also has fewer side effects but is only effective in treating Crohn’s disease in specific parts of the bowel.

Corticosteroids are not intended to be used long-term, however, when they are used short-term they often result in the patient going into induced remission. Then immune suppressors aid in retaining this remission long-term.

Immune system suppressors (Immunosuppressant drugs)

These are kinds of drugs that aid in reducing inflammation. They work through targeting the patient’s immune system (the immune system causes the inflammation). In some cases, these drugs are used in combination with each other.

Immune system suppressors include:

• Mercaptopurine (Purinethol) and azathioprine (Imuran) – These drugs are widely used in treating IBD. Should a patient take these, they should be monitored by their doctor and have regular blood tests in order for their doctor to check for any side effects, one common side effect is the patient’s resistance to potential infections being lowered.  
  
  When these drugs are used short-term they have been associated with the suppression of bone marrow and inflammation of the pancreas or liver. When used long-term, they can result in certain infections, as well as cancers such as skin cancer and lymphoma (these side effects are rare). They can also result in vomiting and nausea. A doctor will administer regular blood tests to check if the patient is able to take these drugs.    

• TNF inhibitors - Adalimumab (Humira), Infliximab (Remicade) and certolizumab pegol (Cimzia) – These kinds of drugs are known as biologics or TNF inhibitors. They work through neutralising a protein made by the immune system known as TNF (tumour necrosis factor). They can also be used to reduce the symptoms of Crohn’s disease that range from mild to severe in children and adults. These drugs can often aid in inducing remission (bringing on a period of disease inactivity). Researchers are still studying these kinds of medications in order to examine and compare their various benefits and side effects.
  
  TNF inhibitors may be used relatively soon after diagnosis has been confirmed, particularly if the doctor thinks that Crohn’s disease is severe or the patient has a fistula. They are also used after other drugs have failed or can be combined with one or more immunosuppressant drugs (this practice is still debated in the medical profession).
  
  There are a number of people who are unable to take any TNF inhibitors due to pre-existing conditions. Severe infections such as tuberculosis (TB) and certain cancers such as skin cancer and lymphoma, have previously been associated with the patient using immunosuppressant drugs. It is best that the patient speaks to their doctor should they suspect they are at risk of TB or any other complications. TB can be tested for through a skin test or an X-ray of the patient’s chest.

• Methotrexate (Rheumatrex) – This kind of drug is used for the treatment of rheumatoid arthritis, psoriasis and cancer and can also be used for those who have not responded well to other treatments for Crohn’s disease.

The short-term effects of this drugs include:          

• Diarrhoea
• Fatigue
• Nausea
• Pneumonia (very rare)

Using this drug long-term can cause:

• Scarring of the liver
• Bone marrow suppression
• Cancer (very rare)

Due to the above side effects, patients are often monitored closely when taking this drug.

• Tacrolimus (Hecoria, Antigraft XL) and cyclosporine (Neoral, Genogram, Sandimmune) – These drugs are extremely potent and are used to aid in the healing of fistulas related to Crohn’s disease. They are typically given to patients who have not responded to any other drugs. Cyclosporine is a drug that can have severe side effects which include:
  • Liver and kidney damage
  • Seizures
  • Fatal infections

These drugs are not intended to be used long-term.

• Vedolizumab (Entyvio)and natalizumab (Tysabri) – These are drugs that work through blocking the binding of specific immune cells known as integrins with other cells found in the intestinal lining (this binding results in inflammation). The drug natalizumab has been approved for those who suffer from Crohn’s disease that is mild to severe, specifically when there is inflammation that has not responded to other drugs.
  
  Due to this drug being associated with the serious but rare risk of progressive multifocal leukoencephalopathy (this is a disease of the brain that can lead to severe disability or even death), the use of this drug requires patients to be enrolled in a specific program for the distribution of this drug in order to be closely monitored.
  
  Vedolizumab has recently been approved for the treatment of Crohn’s disease and does not have the risk of the patient developing brain disease.

• Ustekinumab (Stelara) – This is used in the treatment of psoriasis (a long-term autoimmune disease involving abnormal patches of skin as the condition speeds up the life span of the skin cells causing them to build up rapidly on the skins surface). Studies have also shown that this drug can aid in the treatment of Crohn’s disease and can be used if other drugs do not work.

Antibiotics

These are helpful in reducing the volume of drainage associated with the abscesses and fistulas of Crohn’s disease and in some cases, antibiotics can also heal these abnormalities. Some researchers believe that the use of antibiotics can also aid in reducing the amount of the harmful bacteria in the intestines and can also have a role to play in the activation of the intestinal immune system, this activation leads to inflammation.

Antibiotics work through combatting bacterial infections by attacking the cell wall of the invading or abnormal cells, this injures the cells and prevents the bacteria from attacking and damaging the body any further.

Antibiotics may be used in combination with other medications. If infection is one of the doctor’s concerns, then antibiotics can also aid in treating this. Currently, there is no hard evidence that suggests that the use of antibiotics for Crohn’s disease is effective. The most commonly prescribed antibiotics are:

• Metronidazole (Flagyl) – There was a stage when this drug was the most commonly prescribed antibiotic for the treatment of Crohn's disease, the issue with this drug is that it can result in severe side effects which include:
  • Muscle pain and weakness
  • Tingling or numbness in feet and hands

• Ciprofloxacin (Cipro) – This antibiotic aids in improving the symptoms of some patients who have Crohn's disease. It is often the preferred option over metronidazole as the side effects are less severe, however, tendon rupture has been known to be a rare side effect.

Other medications

Some medications can help in reducing the inflammation and can also aid in relieving some of the patient’s symptoms. The following medications are over-the-counter (OTC) drugs that some doctors may recommend for the treatment of Crohn’s disease:

• Antidiarrhoeals – Fibre supplements can help in relieving the symptoms of diarrhoea as they add bulk to the stool. These should only be used once the patient’s doctor has given the go-ahead. Some of these include:
  • Methylcellulose (Citrucel)
  • Psyllium powder (Metamucil)
  • Loperamide (Imodium)
• Pain relievers – If the patient is suffering from mild pain, then their doctor may suggest they take:
  • Acetaminophen (Tylenol)

Patients will be advised not to take the following:

• Naproxen sodium (Aleve, Anaprox)
• Ibuprofen (Advil, Motrin IB, others)

As these can worsen the symptoms and can possibly cause the disease to progress in its severity.

• Iron supplements – If the patient suffers from severe intestinal bleeding, they may develop anaemia from their lack of iron, they will then need to take iron supplements. These are easy to obtain from a pharmacy and should be clearly labelled.
• Vitamin B-12 injections – Some pharmacies may need a script for these to be administered. Crohn’s disease often results in patients suffering from a deficiency of Vitamin B-12 due to their body’s ability to absorb nutrients being impaired. Vitamin B-12 can help in preventing anaemia, promoting normal and healthy development and growth and is also essential for the proper functioning of the nerves.
• Vitamin D and calcium supplements – The steroids used in the treatment of Crohn’s disease can increase the patient’s risk of developing osteoporosis, this can be prevented through taking Vitamin D and calcium supplements as these promote bone health.

Nutrition therapy

In order for Crohn’s disease to be treated, a doctor may suggest that the patient sticks to a specialised diet that is administered through a feeding tube, this is known as enteral nutrition, or that the nutrients needed are given intravenously, this is known as parenteral nutrition (PN). This method of treatment can help in improving the patient’s overall levels of nutrients and also allow for the bowels to rest, which often results in the short-term reduction of bowel inflammation as the bowels are not aggravated further in having to digest food.

This kind of nutrition therapy may also be combined with medications such as immunosuppressants. Both enteral nutrition and parenteral nutrition are used to improve the overall health of patients before they undergo surgery or if other drugs have failed in controlling the symptoms.

A doctor may also suggest that the patient follows a low-fibre or low-residue diet in order to reduce the number of stools passed as high-fibre stools can result in intestinal blockages, particularly if they suffer from a narrowed bowel, which is known as a stricture.

Surgery

Surgery is often the last treatment option and is conducted when other diet, medications and lifestyle changes have not been effective in relieving the symptoms of Crohn’s disease. Roughly 50% of those who suffer from Crohn’s disease, will have to undergo surgery at least once. Keep in mind, surgery is not able to cure the condition.

During the surgery, the surgeon will remove the portion of the digestive tract that is damaged and then reconnects the sections that are still healthy. Surgery is also utilised to drain any abscesses or to close fistulas. The commonly used procedure for those with Crohn’s disease is known as strictureplasty. This surgery widens the segment of the patient’s intestine that has narrowed.

The surgery will alleviate the narrowing of the bowel that has resulted from the build-up of scar tissue in the intestinal wall from inflammatory bowel diseases.

The downside to surgery is that although it may offer temporary relief to symptoms, Crohn’s disease will often recur near the tissue that has been reconnected.