The treatment of Crohn’s disease is a complicated and sometimes confusing subject. So we asked Dr. Christina Ha, clinical assistant professor of medicine at the Center for Inflammatory Bowel Diseases (IBD) at the UCLA David Geffen School of Medicine, to answer questions and provide some insight on Crohn’s treatments.
What's the most difficult part of treating Crohn's?
The most difficult aspect of Crohn’s disease management is often deciding which of the therapeutics is the most appropriate for the individual based on their disease behavior, severity, and other factors such as their age, co-morbid conditions and family planning. The goals of therapy are to first induce remission, which is ideally an absence of symptoms, and to promote healing, followed by maintenance of remission and improvements in quality of life.
Can you explain a little about each type of Crohn's medication class and their use? The** aminosalicylates** have little role in the treatment of Crohn’s disease—although they are often prescribed to people with mild to moderate disease, particularly people with Crohn’s colitis. However, their efficacy in Crohn’s disease is not as substantial. This is likely due to their primarily “topical” function to treat the colon, whereas Crohn’s disease is a transmural process, meaning it occurs across the entire wall of an organ.
The role of corticosteroids for moderately active Crohn’s disease is primarily as an inductive agent. There is no role of corticosteroids as a maintenance therapy. Long-term use of steroids is associated with several risks, so repeated courses of steroids is not considered an acceptable strategy. Adequate calcium and vitamin D supplementation is necessary while taking steroids, and a bone density test is recommended for people who have received more than three months of steroids during their disease history.
Antibiotics play a limited role as a primary therapy for Crohn’s disease. Based on currently available literature, antibiotics are best used as an addition to other Crohn’s disease therapies.
The thiopurines are used as steroid-sparing maintenance medications for people responding to a course of steroids. These medications have been used for the treatment of Crohn’s disease for more than 50 years, but require monitoring of the complete blood counts and liver enzymes for potential medication-related toxicities. Additionally, for patients with moderate to severe Crohn’s disease, the combination of thiopurines plus biologics may result in better outcomes of remission and healing for certain people.
The biologics, also known as the anti-TNFs, are steroid-sparing agents that have been demonstrated to induce and maintain remission with the potential for mucosal healing. In clinical trials, they have also been shown to be an effective agent for perianal Crohn’s disease and post-operative prophylaxis for higher-risk Crohn’s disease patients following bowel resection to prevent disease recurrence. These agents are given either as an infusion or a self-administered injection at designated intervals. Monitoring for infection—notably tuberculous and hepatitis—before treatment with biologics is very important.
How is treatment different for a flare than for normal daily management?
During flares, which are periods of increased disease activity, more assertive strategies may be required to induce remission. For example, combination therapies with biologics and immunomodulators may be recommended, or a steroid course may be followed. During maintenance, the goal is to keep a person free of Crohn’s symptoms.
Diet and exercise play a big role in managing Crohn's. How does exercise help?
Exercise helps maintain and improve quality of life. Routine weight-bearing exercise is important for people on steroids by improving bone health. People with inflammatory bowel disease (IBD) are at higher risk for developing blood clots, and physical activity may help decrease this risk.
In what ways should a person with Crohn's change his or her diet?
There is no specific “anti-inflammatory” diet that treats Crohn’s disease. However, people who have narrowings of their intestines, called strictures, may benefit from adhering to a low-fiber diet. Foods higher in fiber are more resistant to breakdown by the digestive system and may increase the risk of bowel obstruction. Consult with a registered dietitian to help maintain weight in a healthy manner, as well as monitor for appropriate vitamin and mineral intake.
Are there any other lifestyle changes you'd recommend?
Following treatment therapy is essential, particularly during the maintenance phase when symptoms are dormant, because there is no current cure for the disease. People who routinely take their medications are less likely to have flares and maintain remission longer.
Will there be any new Crohn's treatment options in the near future?
Yes, new treatment targets are currently in phase III clinical trials and are in the pipeline for potential commercial availability. The most promising agents include vedolizumab and ustekinumab, but more targets are being studied.
What can people do to help their doctor treat them to the best of their ability?
A number of things can be done. Here are important steps a patient can take:
Learn more about your disease — there are excellent resources available through the Crohn’s and Colitis Foundation of America.
Remember that no two people with Crohn’s disease are the same. Be cautious about overzealous internet-based searches regarding treatment strategies.
Do your homework and engage in a discourse with your physician regarding your questions about Crohn’s disease and available treatment options.
Keep track of your symptom response and adverse effects.
Adherence to medications improves outcomes—medications don’t work if they are not taken routinely and appropriately.
Keep your healthcare maintenance up to date—this includes vaccinations, bone densitometries, general physical exams, including gynecologic exams, and routine laboratory monitoring.
Stop smoking if you are currently smoking.
Maintain adequate nutrition—consult with a registered dietitian to discuss safe ways to optimize nutrition without further weight loss or adverse consequences.