How is IBD Treated?

Jan 21, 2017 by

You can have me read this article to you instead of reading it yourself…

Or you can read it the old-fashioned way below…


I wish that I could say the discussion on how to treat IBD is very simple, but why would it be?  Wait!  Actually, I can break it down into two very simple components:

  • Remove and alter the affected tissue via surgery
  • Suppress the immune system in order to reduce or halt the inflammation via medications

Ha!  Nailed it!  Next topic!

Yeah, we wish.  Unfortunately, this topic gets much more complex after we branch off of those first two simple categories.

And while I would love to go on and on in great detail about each of the options currently available (I am a pharmacist that geeks out on research and evidence, after all!), an online article is not the best forum for such a discussion.  I hope to release a book in the future that provides detailed, personalized discussions of the different treatment options that are available, and the many considerations that come with each.

For now, we will be limited to a general overview of our options via this website.  I’m not withholding information!  I’m just not unleashing fountains of knowledge that have no place outside of the context of the foundational understanding necessary to utilize that knowledge, and the physician advice that it should always be connected to.

IBD Treatment Options

Now that I have laid all of that on the table, I want to provide the general overview of the treatment options available for IBD.

It’s important for me to start this off by saying that there is no legitimate cure for IBD.  Sometimes, with surgery, IBD can go away.  Although those who have had surgeries will tell you that this introduces another set of issues.  Sometimes, with the right medications, IBD can go into remission.  And hopefully it stays there!  And yet other times, as we’ve already mentioned, some people will have only a single flair and never have one again.

But regardless of the situation, we do not have anything to cure the underlying cause of IBD (autoimmune inflammation).  We are just slowly getting a little bit better at treating it.  So without further ado…

Dietary Changes

There are many discussions and ideas out there regarding the use of diet to treat IBD.  It is important to recognize that small changes to the daily diet are unlikely to have a significant impact on the symptoms of IBD.  However, the elimination of certain foods can definitely improve symptoms.  In addition, there are studies showing that strict formula-only diets used for certain lengths of time can lead to remission.  This will be covered in great detail in another post, which I will link here when it is available (and will also send out a notification to all newsletter subscribers).

Surgical Treatments

As you can imagine, surgical treatment options are not quite inside my wheelhouse the way that medication treatment options are.  And I’m not going to pretend to be an expert on them.  My coverage of them will be brief, and will likely provide links to sources that I think do a splendid job of picking up where my expertise leaves off.

First and foremost, though, I will say that surgery is typically only utilized as a treatment in one of two cases:

  1. After medications have failed to work, OR
  2. In a severe, acute situation that has become a life-threatening medical emergency (ie, toxic megacolon)

Secondly, I will say that surgery with IBD is rarely a case of cutting out the problem, sewing you back up, and sending you along your merry way.  Because it often requires removal or restructuring of large parts of the intestine, there are many long-term complications and ‘fixes’ that must be used post-surgery.

And finally, my discussions of each of these are meant to give a broad understanding for each term that is commonly thrown around.  I will briefly explain what it means, as well as what might lead up to the decision to conduct the surgery and what often happens afterwards.  A doctor will have in-depth discussions with their patients prior to performing these surgeries, and there are also many resources available to help people manage their new needs after the surgery is over.

Colectomy

A colectomy is a removal of the entirety of the colon.  While more commonly used in the treatment of ulcerative colitis, it is used for Crohn’s disease as well.  In this case, the very end of the ileum (the last piece of the small intestine) becomes the new end of the GI tract.  Patients that undergo this surgery will need to have their intestines reworked in such a way that allows for excretion of stool.  We will cover a couple of those options in just a moment.

As I mentioned above, there are two main reasons that this surgery may be performed.  There are also some considerations that might lead someone to decide to have a colectomy completed even when neither of those two situations applies.

Interestingly, many of the non-GI symptoms that can be seen with Crohn’s disease (such as uveitis, polyarthritis, and more) can actually disappear after a colectomy, so when these symptoms are particularly difficult to manage, it may be a reason to consider surgery.  Surgery is also an option for those that are at particularly high risk of developing colon cancer.

Different ways to “re-work” the intestine after colectomy:

Ostomy
One of the classic options for elimination of stool after a colectomy is through the use of an ostomy.  This means that the ileum (the end of the small intestine) will be directed to a new opening in the abdomen (a stoma).  This allows for waste products to be eliminated through this connection and into a bag.

For more information on the management of ileostomies and the complications that come with it, I’d recommend Newbie Ostomy, a thorough reference on how to live well with ostomies from someone who has been there.

J-Pouch (Ileal Pouch-Anal Anastomosis)
This is a creative solution that is popularly used when it can be for people undergoing a colectomy.  The J refers to the configuration that the intestine is placed into before it is sewn in to allow for regular defecation through the anus.  Although it is by no means a perfect solution, it allows for a more natural lifestyle after surgery.

There is a wonderful text and graphic explanation of what a J-Pouch is, how it works, and what can go wrong at Colitis Ninja.  I would be doing everyone a disservice if I didn’t just stop now and send you there instead!

Each of these options are not without significant possible complications, which are outside of the scope of this discussion.

Intestinal Resection

A resection of the intestine means that only a small portion or segment of the intestine is removed.  This can be done to either the small or large intestine, but is typically only utilized with Crohn’s disease.  You will remember that Crohn’s disease often occurs in patches, whereas ulcerative colitis does not.

These resections can be particularly beneficial for people experiencing inflammation in only one area.  However, they do not treat the cause of the condition, so there is no guarantee that a relapse will not occur down the road.  This appears to happen for about half of the people that have an intestinal resection.

While this surgery is less invasive and requires less restructuring than with a colectomy, there are still complications that can occur.  Sizable resections of the small intestine can impair the body’s ability to absorb nutrients from the food that is eaten.  This can lead to a serious case of malnutrition that is referred to as short bowel syndrome.

Strictureplasty

This surgery is conducted when the passageway in the intestine has become incredibly thin and narrow, which may lead to a blockage for the contents that must pass through.  Having this procedure completed avoids the need for removal of the intestine, and simply functions to widen these narrowed passages.

Intestinal Transplant

If so much small intestine has been removed (resected) that the body can no longer absorb any nutrients, then an intestinal transplant may be considered.  I won’t go into any detail on this, because it is a rare procedure that will only be considered in a small number of cases after many complications have occurred (including short bowel syndrome).

Medications to Treat IBD

As I said previously, the goal of medication treatments is to suppress the immune system.  These drugs are called immunosuppressants.  The classic medications in this class (which have many well-recognized side effects, including moon face and weight gain) are steroids.  The typical one that is taken for IBD is prednisone.  Steroids are powerful, but they have many side effects throughout the entire body, especially when used for an extended length of time because of their broad-spectrum approach to beating down the immune system.

We are lucky to have access to medications that are more targeted, which reduces side effects and makes the medications more tolerable for long term use.

Medications that Stay in the Intestine

One development that has been made is the production of steroids and other immunosuppressants that stay inside of the gut.  That means that once they have been swallowed (or administered via an enema), they are never absorbed into the body.  All of the benefits and side effects are isolated to the gut.  These have been incredibly beneficial options, albeit more so for those with ulcerative colitis, because they cut down so dramatically on side effects and allow for long-term use.

Narrow Spectrum Immunosuppressants

Another development has been the creation of drugs that focus in on certain parts of the immune system, and specifically those parts that are most active in causing the inflammation found in IBD.

Some of these drugs are taken by mouth, but some of them are administered by injection.  These have been incredibly beneficial for many people with both forms of IBD and can induce remission.  They need to be used consistently to maintain remission.  The schedules for administering the drugs that are given via injection may be somewhat strange.  Some may require once weekly shots, others are infusions that must be run over a few hours every couple of months, etc.

Risks of Immunosuppressants

In general, the options have gotten much better, but they are by no means perfect.  They do not work for everyone and they are not without side effects.  As you would expect from medications that suppress the immune system, all of these medications can make you more susceptible to infection.  However, one of the benefits of the more specific drugs that have been developed is that they only increase susceptibility to certain types of infections.  In addition, a reduction in the immune system can also increase susceptibility to development of cancer in your lifetime.

There are a number of other side effects, risks, and considerations with each of these medications, but that falls outside of the scope of this article.

I will at least provide a list of the medications that fall into these categories.  Each of these medications has its own pros and cons and each would be considered only in specific cases (ulcerative colitis vs Crohn’s disease, moderate vs severe, first option vs second option vs third option, etc).

Oral and Rectal Medications

  • Broad-Spectrum Immunosuppressants
    • Steroids (prednisone, methylprednisolone)
  • Broad-Spectrum Immunosuppressants [That stay in the gut]
    • Budesonide (Entocort, Uceris)
  • Narrow Immunosuppressants
    • Azathioprine (Imuran)
    • Cyclosporine (Neoral, SandImmune)
    • Mercaptopurine
    • Methotrexate
  • Narrow Immunosuppressants [That stay in the gut]
    • Mesalamine (Delzicol, Pentasa, Apriso, Rowasa, Canasa, Asacol, Lialda)
    • Balsalazide (Colazol)
    • Sulfasalazine (Azulfidine)
    • Olsalazine (Dipentum)

Injectable Medications

  • Narrow Immunosuppressants
    • Adalimumab (Humira)
    • Infliximab (Remicade)
    • Certolizumab (Cimzia)
    • Vedolizumab (Entyvio)

Medications to Treat Symptoms

I won’t go into any detail here, but I would be remiss not to mention the wide array of medications that may be needed to treat some of the symptoms and complications that come with IBD.  I will likely post articles regarding some of these topics on the website in the future, at which point I will link them here.  And when that book of the future is finally produced, it will cover these topics in great detail.  But until then, the other reasons to use medications with IBD will include, but will not be limited to:

  • Diarrhea
  • Infection
  • Nutritional deficiencies
  • Fatigue
  • Abdominal pain
  • Insomnia
  • Blood loss

Interested in more information on IBD?

Next: What is the Difference Between IBD and IBS?

Or refer back to the IBD Info Hub.

 


Trivia and Terminology:

Short Bowel Syndrome is a condition in which the intestines are no longer able to absorb enough nutrients into the body because so much intestine is missing (hence the “short” in the name)

Immunosuppressants are medications that reduce the strength of the body’s immune system, something that is particularly helpful when the body’s immune system is attacking its own body

 

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