digestive disorders
Crohn Disease
Treatment of Crohn Disease
Antidiarrheal medications Aminosalicylates Corticosteroids Immunomodulating medications Biologic agents Small-molecule agents Antibiotics Dietary regimens Sometimes surgery Many treatments of Crohn disease help reduce inflammation and relieve symptoms. Cramps and diarrhea may be relieved by takingloperamideor medications that stop spasms in the abdomen (ideally before meals).Methylcelluloseorpsylliumpreparations sometimes help prevent anal irritation by making the stool firmer. People should avoid eating fiber during flare-ups or if they have intestinal blockage. Health maintenance , particularly vaccinations and cancer screening, are important. These medications, which may relieve cramps and diarrhea, include diphenoxylate,loperamide, deodorized opium tincture, andcodeine. They are taken by mouth—preferably before meals. Aminosalicylates are medications used to treat inflammation caused by Crohn disease.Sulfasalazineand related medications such asmesalamine,olsalazine, andbalsalazideare types of aminosalicylates. These medications can suppress symptoms when they occur and reduce inflammation, especially in the large intestine. Typically these medications are taken by mouth.Mesalamineis also available as a suppository or enema. Aminosalicylates do not work as well for relieving severe flare-ups. Corticosteroids, such asmethylprednisolone, that are given by vein (intravenously) may dramatically reduce fever and diarrhea, relieve abdominal pain and tenderness, and improve appetite and sense of well-being in hospitalized people. However, long-term use of corticosteroids causes side effects (see sidebar). Usually, high doses are taken initially to relieve major inflammation and symptoms caused by sudden flare-ups. The dose is then reduced and the medication is discontinued as soon as possible. Another corticosteroid calledbudesonidehas fewer side effects thanprednisone, but it may not be quite as rapidly effective and usually does not prevent relapses beyond 6 months.Budesonidecan be given by mouth or as an enema. As with corticosteroids taken by mouth, the dose of corticosteroids taken in enema or foam form (such ashydrocortisone) is reduced and gradually stopped. If the disease becomes severe, the person is hospitalized and corticosteroids are given by vein (intravenously). Doctors givevitamin Dand calcium supplements to all people who take corticosteroids. Azathioprineandmercaptopurineare medications that decrease the actions of the immune system. They are effective for people with Crohn disease who do not respond to other medications and are especially effective for maintaining long periods of remission (periods of no symptoms). They significantly improve the person's overall condition, decrease the need for corticosteroids, and often heal fistulas. However, these medications may not produce benefits for 1 to 3 months and may have potentially serious side effects. are nausea, vomiting, and a general feeling of illness (malaise). A doctor closely monitors the person for other side effects such as allergic reactions, suppression of bone marrow (monitored by regularly measuring white blood cell counts), inflammation of the pancreas ( Overview of Pancreatitis ), and sometimes liver problems. People who take these medications have an increased risk of developing Blood tests that detect variations in one of the enzymes that metabolizeazathioprineandmercaptopurineand that directly measure metabolite levels often help the doctor ensure safe and effective medication dosages. should make sure the female partner uses an effective Overview of Contraception (birth control) such as an Cyclosporineis given by injection in high doses. This medication may help heal fistulas caused by Crohn disease, but it cannot safely be used long term because of side effects such as kidney problems, infections, and seizures. Tacrolimusis given by mouth. This medication may help heal fistulas caused by Crohn disease. Side effects are similar to those ofcyclosporine. Infliximab,a biologic agent, is another modifier of the immune system's actions.Infliximabis given as a series of infusions by vein. This medication can be given to treat moderate to severe Crohn disease that has not responded to other medications, to treat people with fistulas, and to maintain response when the disease is difficult to control. Side effects that may occur withinfliximabinclude worsening of an existing uncontrolled bacterial infection, reactivation of tuberculosis or hepatitis B, and an increase in the risk of some types of cancer. Some people have reactions such as fever, chills, nausea, headache, itching, or rash during the infusion (called infusion reactions). Before starting treatment withinfliximab(or other biologic agents such asadalimumab, certolizumab,vedolizumab, andustekinumab), people must be tested for tuberculosis and hepatitis B infection. Adalimumabis a medication related toinfliximaband also focuses on regulating the immune system.Adalimumabis given as a series of injections under the skin (subcutaneous injections) and so does not cause the possible infusion reactions of a medication given by vein such asinfliximab.Adalimumabis particularly helpful for people who cannot tolerate or who no longer respond toinfliximab. People may have pain and itching at the injection site. Certolizumabis given as monthly subcutaneous injections. This medication works in a similar way as and causes side effects similar to those ofinfliximabandadalimumab. is currently available only through a restricted-use program because it increases the risk of a fatal brain infection called Progressive Multifocal Leukoencephalopathy (PML) (PML). Ustekinumabis another kind of biologic agent. The first dose is given by vein and then by injections under the skin every 8 weeks. Side effects include injection-site reactions (pain, redness, swelling), cold-like symptoms, chills, and headache. Risankizumabis used to treat moderate to severe Crohn disease. The most common side effects are headaches, fatigue, common cold, and rare candida (yeast) infections. Severe allergic reactions are very rare, but skin reactions at the site of the injection may occur. Upadacitinibis a Janus kinase inhibitor taken orally that is used to treat Crohn disease and ulcerative colitis. The most common side effects of this medication are acne, folliculitis (infections at the hair follicles), upper respiratory tract infection, hypersensitivity reactions, nausea, and abdominal pain. It increases risk for developing serious infection, heart attack, stroke, venous thrombosis (blood clot), pulmonary embolism, and arterial thrombosis. Biosimilars are biologic medications that are very similar to a reference biologic product. Some biosimilars are commercially available. Antibiotics that are effective against many types of bacteria are often prescribed. The antibioticmetronidazoleis the most common choice for the treatment of abscesses and fistulas around the anus.Metronidazolemay also help relieve the noninfectious symptoms of Crohn disease, such as diarrhea and abdominal cramps. However, when used for a long time,metronidazolecan damage nerves, resulting in a pins-and-needles feeling in the arms and legs. This side effect usually disappears when the medication is stopped, but relapses of Crohn disease after discontinuingmetronidazoleare common. People should avoid consuming alcoholic beverages or products containing propylene glycol while takingmetronidazoleand should continue to avoid these substances for at least 3 days aftermetronidazoletreatment is completed. Some other antibiotics, such asciprofloxacinorlevofloxacin, may be used in place of or in combination withmetronidazole.Rifaximin, a nonabsorbable antibiotic, is also sometimes used in treating active Crohn disease. Some bacteria are naturally found in the body and promote the growth of good bacteria (probiotics). The daily use of probiotics, such aslactobacillus(typically present in yogurt), may be effective in preventing pouchitis (inflammation of a reservoir created during surgical removal of the large intestine and rectum). Although some people claim that certain diets have helped improve their Crohn disease, diets have not been shown to be effective in clinical trials. Nutritional therapy may help children grow more than they might otherwise, especially when given at nighttime by tube feeding. Occasionally, concentrated nutrients are given intravenously to compensate for the poor absorption of nutrients that is typical of Crohn disease. Most people with Crohn disease require surgery at some point during their illness. Surgery is needed when the intestine is obstructed or when abscesses or fistulas do not heal. An operation to remove diseased sections of the intestine may relieve symptoms indefinitely, but it does not cure the disease. Crohn disease tends to recur where the remaining intestine is rejoined, although several medication therapies initiated after surgery reduce this tendency. A second operation is ultimately needed in nearly half of the people. Consequently, surgery is done only if specific complications or the failure of medication treatment makes it necessary. Still, most people who have undergone surgery consider their quality of life to be better than it was before the operation. Because smoking increases the risk of recurrence, especially in women, doctors encourage people to Smoking Cessation . People who have severe disease may be hospitalized and given intravenous fluids to restore and maintain body fluids (hydration). Some people who have heavy rectal bleeding may require blood transfusions. People who have more chronic anemia may need iron supplements taken by mouth or given intravenously. For people who have mild to moderate symptoms,mesalamineis typically the first medication of choice. Some doctors give antibiotics instead ofmesalamineor give antibiotics to people who are not helped bymesalamine. For people who have moderate to severe symptoms,corticosteroids (such asprednisoneorbudesonide) are given by mouth or vein for short periods of time. People who are not helped by corticosteroids are given other medications such asazathioprine,mercaptopurine,methotrexate,infliximab,adalimumab, certolizumab,vedolizumab,risankizumab,upadacitinib, orustekinumab. A combination of these medications may be given. These medications help most people. If people have a blockage, doctors do nasogastric suction and give fluids by vein. In nasogastric suction, a tube is passed through the nose into the stomach or small intestine, and suction is applied to the tube to relieve abdominal swelling (distention). For people whose symptoms developed suddenly or who have an abscess,fluids and antibiotics are given by vein in a hospital. Doctors drain the abscess surgically or by inserting a needle under the skin and drawing out the fluid. People with fistulas around the anus (perianal Anorectal Fistula ) are given To help keep symptoms from returning (that is, to maintain remission), people who require only an aminosalicylate or antibiotic to achieve remission can continue to take these medications. People who were treated with a combination of medications, such asazathioprine,mercaptopurine,methotrexate,infliximab,adalimumab, certolizumab,vedolizumab,risankizumab,upadacitinib, and/orustekinumab, need to continue taking these medications to maintain remission. People being treated with corticosteroids should have their doses gradually reduced. To maintain remission, they may need a combination of the medications mentioned here. During remission, doctors monitor people's symptoms and do blood tests. Routine x-rays or colonoscopy does not need to be done (except in people who have had Crohn disease for 7 or 8 years or longer). 