Dr Stephen John Middleton MA MD FRCP FAHE

Consultant Gastroenterologist

Inflammatory Bowel Disease (IBD)

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The treatment of inflammatory bowel disease can be divided into two stages:

1. Inducing disease remission.
2. Maintaining disease remission.

The types of treatment available range from dietary modification to very potent immunosuppression, some of these are aimed at inducing disease remission others at maintaining remission.  Several treatments achieve both these aims.

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Diatary Treatments
It has been known for many years that liquid elemental diets can induce remission in Crohn’s disease. They have not been shown to be effective in ulcerative colitis. The elemental diets are based on a very simple diet which is made up of nutritional components in their simplest forms. This means that very little digestion is required and most of the feed is absorbed easily in the small intestine. This type of treatment is very effective in inducing disease remission and can also maintain disease remission, but is often found unpleasant to taste and may need to be delivered by a naso-gastric tube. It is often used as the primary treatment in children and can also be used effectively in adults.
  After achieving remission on an elemental diet some centres proceed on to an exclusion diet. This is designed to identify foods that provoke symptoms and therefore might be causing a recurrence of inflammation.
Drug Treatments
Crohn’s disease
Drugs used to induce remission in Crohn’s disease

Steroids
Anti –TNF antibodies
  ( Some physicians use antibiotics although the evidence for their effectiveness is not conclusive)
  Steroids –  used either orally or topically as an enema depending upon the site of the disease. When the disease is severe they can be given intravenously and this is more effective that the oral route. Some steroid preparations limit the amount of steroid drug that enters the body thus reducing the side effects. Steroids such as  Budesonide treat at the point where they are absorbed, rather than going through the blood stream. Any drug that is absorbed is largely  removed from the blood stream by the liver. Budesonide preparations are mainly used for small intestine and right colonic (top of the colon near the small intestine) disease but new formulations are being developed which may prove to be effective for treatment of the left colon also. They should not be used to maintain disease remission.


Anti-TNF antibodies -This type of treatment uses antibodies which attack a substance called TNF- a (Tumour necrosis factor alpha). This substance is released during inflammation and is a very strong promoter of further inflammation especially in Crohn’s disease. These drugs can either be infused into a vein every few months or given at home by injection every two weeks. They have side effects including an increased  risk of infections and can cause allergic reactions but are generally well tolerated. They can also be used to maintain disease remission.
Drugs used to maintain remission in Crohn’s disease
Imunosuppression
Certain drugs are known to have a suppressing effect on the immune system. Some of these have been demonstrated to be effective as treatments for Crohn’s disease.
Azathioprine :  
This is the most frequently used immunosupressive drug in the UK. It can take up to 3 months to have its effect and can adversely effect bone marrow function and the liver. Patients need to be closely monitored when starting the drug and continue to have regular check ups whilst on it. It can have extremely beneficial effects.
Methotrexate:
Another imunosupessive drug which has been shown to be beneficial in Crohn’s disease but is not as well established as azathioprine. Again, close monitoring is required and long term side effects such as lung fibrosis and liver fibrosis can rarely occur. Drug interactions should be watched for and alcohol intake minimised.
Anti-TNF alpha antibodies:
Also used as maintenance tx in Crohn’s disease.
Drugs used to induce remission in ulcerative colitis
These are broadly similar to those used in Crohn’s disease.   However, Anti TNFa antibodies are not used as often as the evidence for their effectiveness is less compelling. Nevertheless the studies available do demonstrate a beneficial effect in ulcerative colitis.
Drugs used to maintain remission in ulcerative colitis
These are broadly similar to those used in Crohn’s disease, above.   However, 5-ASA compounds have been found to be effective as maintenance treatment for UC, although they are not thought to be effective in Crohn’s disease to maintain remission.   Methotrexate has not been demonstrated to be very effective in ulcerative colitis although there have not been many studies undertaken.  
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