treatment for crohn's disease

Crohn’s disease is a type of Inflammatory Bowel Disease caused by inflammation in the digestive tract. Crohn’s disease can affect different parts of the gastrointestinal tract, including the small intestine, large intestine, and colon.

The most common symptoms of Crohn’s disease are chronic diarrhea and abdominal pain. Other symptoms can include fatigue, fever, blood in the stool, and weight loss.

Although the exact causes of Crohn’s disease are unknown, it is generally thought that the immune system is involved in the development of the disease. Genetic susceptibility may also be an important factor, since you are at higher risk of Crohn’s disease if a family member also has this disease. Other risk factors include age, history of smoking or taking non-steroidal anti-inflammatory medications. 

How is it Diagnosed?

Your doctor will diagnose Crohn’s disease using information that is gathered from a medical history and various medical tests. Some tests your doctor may use include blood tests, colonoscopy, CT scans, or MRI,

Treatment for Crohn’s Disease

The goal of treatment for Crohn’s disease is to reduce inflammation that is responsible for causing pain and other symptoms. Long-term remission is possible if a successful treatment is found, which can limit the long-term serious damage that can be caused by this disease.

Your doctor will also consider how severe your Crohn’s disease is, and primary location, before prescribing medication. You may not be able to take certain medications depending on whether you have any other medical condition or if you are (or may become) pregnant – these conditions may make some medications unsafe for you to take.

Corticosteroids

Corticosteroids are considered as first-line treatment for Crohn’s disease. Clinical trials have demonstrated that oral corticosteroids have significant benefit in inducing remission in patients, when compared to placebo treatment. However, long-term treatment with corticosteroids is not recommended due to significant side effects.

Budesonide

Oral budesonide acts to reduce inflammation, and is typically used for patients with mild to moderate Crohn’s disease.

Although budesonide has been associated with less side effects compared with other corticosteroids, its side effects can include headache, nausea, vomiting, diarrhea, and fatigue. Budesonide can also have some serious side effects, such as suppression of the immune system and serious allergic reactions.

Clinical study has demonstrated that budesonide significantly improves the chances of inducing remission in patients with Crohn’s disease.

Prednisone

For patients who don’t respond to budesonide treatment, prednisone is recommended. Side effects of prednisone can include weight gain, increased blood pressure, headache, nausea, vomiting, and muscle weakness. Prednisone can also have some serious side effects, such as stomach ulcers or cardiovascular side effects.

Immunosuppressants

Immunosuppressants act to reduce immune-related activity, ultimately inhibiting processes involved in inflammation. These treatments are typically used to maintain remission in patients with Crohn’s disease.

Azathioprine (Azasan, Imuran) & Mercaptopurine (Purinethol, Purixan)

These drugs are commonly used in an effort to reduce the amounts of steroids that patients are taking. Although these treatments have been found to be no more effective than placebo in clinical trials, they are often used in combination with other treatments and allow a reduction in the amount of steroids being taken.

Methotrexate (Trexall). This drug is sometimes used for people with Crohn’s disease who don’t respond well to other medications. You will need to be followed closely for side effects.

Biologics

Biologics agents, such as antibodies, are approved for treating patients with Crohn’s disease. These agents can have significant side effects that can include serious infections and increased risk of cancer.

TNF-inhibitors

These drugs, called TNF inhibitors or biologics, work by neutralizing an immune system protein known as tumor necrosis factor (TNF).

TNF inhibitors can be used to induce or maintain remission in patients that have not previously responded to other treatments. Clinical trials have demonstrated significant benefits of the TNF inhibitors infliximab (Remicade), adalimumab (Humira), and certolizumab (Cimzia), which have been found to both induce and maintain remission in patients with Crohn’s disease. Clinical trials have found no significant benefit of one anti-TNF drug over another. 

Anti-integrins

Anti-integrins are antibodies that are directed against proteins called integrins. The anti-integrin drugs natalizumab (Tysabri) and vedolizumab (Entyvio) can be used to treat Crohn’s disease.

Natalizumab is associated with significant side effects and only a subset of patients are considered for this treatment. Vedolizumab acts similarly to natalizumab, but does not appear to have the same significant adverse effects. In clinical trials vedolizumab has been found to be effective at both inducing and maintaining remission in patients with Crohn’s disease.

Ustekinumab (Stelara)

Ustekinumab (Stelara) is a monoclonal antibody that attaches to a portion of the cytokines interleukin-12 (IL-12) and interleukin-23 (IL-23), inhibiting their activity. Previously used as a treatment for psoriasis, ustekinumab is now approved for use in patients with Crohn’s disease.

Clinical studies that included patients with Crohn’s disease that was no longer responding to other treatments, or were not successfully treated using a TNF inhibitor, ustekinumab was able to induce and maintain remission in patients who had previously been treated with anti-TNF therapy.

It is important to note that ustekinumab carries risks of significant infection, including tuberculosis, and longer-term studies will be needed to determine any long-term side effects associated with this treatment.

References:

Lichtenstein, Gary R MD, FACG1; Loftus, Edward V MD, FACG2; Isaacs, Kim L MD, PhD, FACG3; Regueiro, Miguel D MD, FACG4; Gerson, Lauren B MD, MSc, MACG (GRADE Methodologist)5,†; Sands, Bruce E MD, MS, FACG6 ACG Clinical Guideline: Management of Crohn’s Disease in Adults, American Journal of Gastroenterology: April 2018 – Volume 113 – Issue 4 – p 481-517 doi: 10.1038/ajg.2018.27 https://journals.lww.com/ajg/Fulltext/2018/04000/ACG_Clinical_Guideline__Management_of_Crohn_s.10.aspx

Clinical Practice Guidelines. Journal of the Canadian Association of Gastroenterology, 2019, 2(3), e1–e34 doi: 10.1093/jcag/gwz019 https://www.cag-acg.org/images/publications/CAG-CPG-Luminal-Crohns-Disease-JCAG-July2019.pdf

Mahesh Gajendran, Priyadarshini Loganathan, Anthony P. Catinella, Jana G. Hashash. A comprehensive review and update on Crohn’s disease, Disease-a-Month, Volume 64, Issue 2, 2018, Pages 20-57, ISSN 0011-5029. https://www.sciencedirect.com/science/article/abs/pii/S0011502917301530?via%3Dihub

Veauthier B, Hornecker JR. Crohn’s Disease: Diagnosis and Management. Am Fam Physician. 2018;98(11):661-669. https://www.aafp.org/afp/2018/1201/p661.html

Shi, H. Y., & Ng, S. C. (2018). The state of the art on treatment of Crohn’s disease. Journal of gastroenterology53(9), 989–998. https://doi.org/10.1007/s00535-018-1479-6

Lamb, Y.N., Duggan, S.T. Ustekinumab: A Review in Moderate to Severe Crohn’s Disease. Drugs 77, 1105–1114 (2017). https://doi.org/10.1007/s40265-017-0765-6 https://link.springer.com/article/10.1007/s40265-017-0765-6

Image by Oberholster Venita from Pixabay 

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