Treatment of inflammatory bowel disease

The goal of medical treatment is to reduce the inflammation that triggers your signs and symptoms. In the best cases, this may lead not only to symptom relief but also to long-term remission. Treatment for ulcerative colitis usually involves either drug therapy or surgery.
Doctors use several categories of drugs that control inflammation in different ways. But drugs that work well for some people may not work for others, so it may take time to find a medication that helps you. In addition, because some drugs have serious side effects, you’ll need to weigh the benefits and risks of any treatment.

Anti-inflammatory drugs

Anti-inflammatory drugs are often the first step in the treatment of inflammatory bowel disease. They include:

Sulfasalazine

This was the first drug that was found to be useful in ulcerative colitis. Although it can be effective in reducing symptoms of the disease, it has a number of side effects, including nausea, vomiting, heartburn and headache. Don't take this medication if you're allergic to sulfa medications.

Mesalamine

These medications tend to have fewer side effects than sulfasalazine has. They are available in tablet form and as enemas or suppositories. Mesalamine enemas can relieve signs and symptoms in more than 80 percent of people with ulcerative colitis in the lower left side of their colon and rectum.

Balsalazide

This is another formulation of mesalamine. Balsalzide delivers anti- inflammatory medication directly to the colon. The drug is similar to sulfasalazine, but uses a less toxic carrier and may produce fewer side effects.

Corticosteroids

Steroids can help reduce inflammation, 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, type 2 diabetes, osteoporosis, bone fractures, cataracts and an increased susceptibility to infections. Long-term use of these drugs in children can lead to stunted growth. Also, corticosteroids don't work for about half of patients who have ulcerative colitis or Crohn's disease. Doctors generally use corticosteroids only if you have moderate to severe inflammatory bowel disease that doesn't respond to other treatments (mesalamine tablet or enema). Corticosteroids aren't for long-term use and are generally prescribed for a period of three to four months. They may also be used in conjunction with other medications as a means to induce remission. For example, corticosteroids may be used with an immune system suppressor because the corticosteroids can induce remission, while the immune system suppressors can help maintain remission. Occasionally your doctor may also prescribe steroid enemas or foam to treat disease in your lower colon or rectum. These, too, are only for short-term use.

Budesonide

This is also a steroid but is destroyed by liver and hence has lesser side effects than standard steroids such as prednisone. The drug is delivered in terminal ileum and adjacent colon and is useful for inflammation in these areas. An enema form is also available.

Immune system suppressors

These drugs also reduce inflammation, but they target the immune system rather than treating inflammation itself. An overactive immune response damages the digestive tissues in inflammatory bowel disease. By suppressing this response, inflammation is also reduced. Immunosuppressant drugs include:

Azathioprine and mercaptopurine

These drugs have been used to treat Crohn's disease initially and ulcerative colitis later. Because azathioprine and mercaptopurine act slowly (they take about 2 months), they're sometimes initially combined with a corticosteroid, but in time, they seem to produce benefits on their own, with less long-term toxicity. Side effects are not minor, however, and can include allergic reactions, bone marrow suppression, infections, and inflammation of the liver and pancreas. These need regular monitoring

Cyclosporine

This potent drug is normally reserved for people who don't respond well to other medications or who face surgery because of severe ulcerative colitis. In some cases, cyclosporine may be used to delay surgery until patients are strong enough to undergo the procedure; in others, it's used to control signs and symptoms until less toxic drugs start working Cyclosporine begins working in one to two weeks, but because it has the potential for severe side effects including kidney and liver damage, fatal infections and an increased risk of lymphoma, the risks and benefits of treatment must be carefully weighed.

Methotrexate

This drug is useful in patients with Crohn's disease. Side effects include bone marrow suppression, liver toxicity on prolonged use. Women of childbearing age need to practice contraception, as this can be harmful to fetus.

Biologic agents

As we learnt earlier that inflammatory bowel disease results from an immunological response to antigen or protein. Biological agents are antibodies to such proteins. These agents are considered when earlier mentioned drug are not effective, not tolerated or side effects.

Infliximab was the first of these agents but now many other agents are available.

Infliximab

It works by neutralizing a protein produced by the immune system known as tumor necrosis factor (TNF). Infliximab finds TNF in the bloodstream and removes it before it causes inflammation in your intestinal tract. The antibodies are in part human and in part murine (mouse/rat). Some people with heart failure and people with multiple sclerosis and those with cancer or a history of cancer can't use infliximab. The drug has been linked to an increased risk of infection, especially tuberculosis, and may increase your risk of blood problems and cancer. It is used when other treatment does not work. The cost is significantly high.

Adalimumab

It acts like infliximab but is pure humanized. One advantage of Adalimumbab is that it can be administered subcutaneously as against infliximab, which needs to be administered intravenously.

Other Biologic agents

Many are being investigated for efficacy in inflammatorybowel disease and they are finding their place in the management of the disease At present they are not available in India but may be available in couple of years.

Biosimilar drugs

These are compounds which are similar in structure to biologic drugs (but not the same) and are less expensive than biologics

Probiotics

Probiotics are living organisms in foods and dietary supplements that beneficially affect the host by improving its intestinal microbial balance. These agents may be useful as an adjunctive treatment in ulcerative colitis. Their main use is in people who have pouch after an operation.

Antibiotics

Antibiotics (metronidazole and ciprofloxacin) are often useful in Crohn's disease, especially in perianal disease. They may be useful in Crohn's disease where there is an infection. Antibiotic have no role in routine management of ulcerative colitis