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Tuesday, March 11, 2008

Crohn's Disease - Treatment Overview

The main treatment for Crohn's disease is medicine to stop the inflammation in the intestine and medicine to prevent flare-ups and keep you in remission. A few people have severe, persistent symptoms or complications that may require a stronger medicine, a combination of medicines, or surgery. The type of symptoms you have and how bad they are will determine the treatment you need.

Initial treatment

Your doctor will most likely start with the traditional first-line treatment for Crohn's disease. He or she will then add or change medicines if you are not getting better.

Mild symptoms may respond to an antidiarrheal medicine such as loperamide (Imodium A-D, for example), which slows or stops the painful spasms in your intestines that cause symptoms.

For mild to moderate symptoms, your doctor will probably have you take:

  • Aminosalicylates (such as sulfasalazine or mesalamine). These medicines help manage symptoms for many people who have Crohn's disease.
  • Antibiotics such as ciprofloxacin and metronidazole may be tried if aminosalicylates are not helping your symptoms. These medicines work especially well for disease in the colon. Antibiotics are also used to treat fistulas, which are abnormal connections or openings between two organs or parts of the body. But 50% of fistulas come back when antibiotics are stopped.2
  • Corticosteroids (such as budesonide or prednisone) may be given by mouth for a few weeks or months to control inflammation. But corticosteroids have serious side effects, such as high blood pressure, osteoporosis, and increased risk of infection.
    • Budesonide causes remission in mild or moderate Crohn's disease of the ileum and the right colon. It does not work as well as prednisone or other corticosteroids. But it also does not have as many side effects as other corticosteroids. The long-term side effects are not well known, so your doctor will probably not have you take it for a long time.
    • Prednisone may help if budesonide does not.
  • Medicines that suppress the immune system (called immunomodulator medicines), such as azathioprine (AZA), 6-mercaptopurine (6-MP), or methotrexate. You may take these if the medicines listed above do not work, if your symptoms come back when you stop taking corticosteroids, or if your symptoms come back often, even with treatment.

If you have tried all the medicines listed above and none of them have worked, your doctor may give you a tumor necrosis factor (TNF) antagonist such as infliximab (Remicade). This drug may work for people who have not had any success with other medicines for Crohn's disease. Infliximab is also used to treat fistulas if antibiotics do not heal them. Another TNF antagonist that may be used to treat Crohn's disease is adalimumab (Humira). It may work for people for whom infliximab has stopped working and for people who have a bad reaction to infliximab.

Severe symptoms may be treated with corticosteroids given through a vein (intravenous, IV) or TNF antagonists. With severe symptoms, the first step is to control the disease. When your symptoms are gone, your doctor will probably have you start taking one of the medicines listed above to keep you symptom-free (in remission).

Ongoing treatment

Ongoing treatment is designed to find a medicine or combination of medicines that keeps Crohn's disease in remission.

If aminosalicylates (such as sulfasalazine or mesalamine) or immune system suppressors (such as azathioprine [AZA], 6-mercaptopurine [6-MP], or methotrexate) keep your disease in remission, you will continue taking the medicines. Your health professional will want to see you about every 6 months if your condition is stable or more frequently if you have flare-ups. You may have laboratory tests every 2 to 3 months.

Corticosteroids (such as budesonide, hydrocortisone, or prednisone) may be given to stop inflammation if you have flare-ups of symptoms. If you need to take corticosteroids for an extended time, you also may receive calcium, vitamin D, and prescription medicine to prevent osteoporosis.

Tumor necrosis factor (TNF) antagonists such as infliximab (Remicade) and adalimumab (Humira) are also used as maintenance medicines.

Treatment if the condition gets worse

If you have severe Crohn's disease, you will most likely be given infliximab (Remicade). This drug may be prescribed if Crohn's disease does not get better with medicines that suppress the immune system (such as azathioprine [AZA], 6-mercaptopurine [6-MP], or methotrexate). Infliximab may also be given if your symptoms come back when you try to stop taking corticosteroids. Infliximab is given in a vein (intravenous, IV).

If infliximab does not work for you, or if you cannot take it because of a serious side effect, you may be given adalimumab (Humira). Adalimumab is given as a shot under the skin (subcutaneous).

If you have a very bad flare-up of Crohn's disease, you will most likely need IV corticosteroids (like hydrocortisone) to get the disease under control.

Some severe cases of Crohn's disease need to be treated in the hospital where you would receive supplemental nutrition through a tube placed in your nose and down into the stomach (enteral nutrition). In other cases, the bowel may need to rest, and you will be fed liquid nutrients in a vein (total parenteral nutrition, TPN). Supplemental nutrition may be necessary if you are malnourished because of severe Crohn's disease in the small intestine. Nutritional support is especially important for children who are not growing normally because of severe disease.

Surgery may be needed if no medicine is effective, you have serious side effects from medicine, your symptoms can be controlled only with long-term use of corticosteroids, or you develop complications such as fistulas, abscesses, or bowel obstructions. Surgery involves removing the affected portion of the intestines, preserving as much of the intestines as possible to maintain normal function. Unfortunately, Crohn's disease tends to return to other areas of the intestines after surgery.
WebMD Medical Reference from Healthwise

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