How Crohn's Disease Is Treated

Crohn's disease is a chronic inflammatory bowel disease that primarily affects the lining of the digestive tract. While it cannot be cured, there are medications such as steroids and immune suppressants that can slow the progression of the disease and help you achieve sustained periods of remission. You can also treat symptom flares with diet, bowel rest, and an increased intake of soluble fiber. If Crohn’s disease causes injury to your intestines, such as a perforation or blockage, surgery may be needed.

While Crohn’s disease can cause great anxiety and frustration, by working closely with your doctor and gastroenterologist, you will eventually be able to find the treatments able to minimize your symptoms and help you live a full and productive life.

Prescriptions

For most people with Crohn's disease, prescription treatment is necessary for long-term control of disease progression. A variety of medications may be used. They can be broken down into five classes, each of which has a different mechanism of action appropriate to different stages of the disease.

Aminosalicylates

Aminosalicylates help control inflammation and are typically used in newly diagnosed people with mild symptoms. They are available in pill, liquid, suppository, and enema formulations and can be used on an ongoing basis to keep the disease in remission.

While experts don’t fully understand how they work, aminosalicylates are believed to temper the production of inflammatory chemicals known as cytokines. Options include:

Side effects include diarrhea, headaches, and heartburn.

Antibiotics

Antibiotics are used to treat bacterial infections common in people with Crohn's disease. They may occur as a result of a fissure (a cut or tear in the intestine) or a fistula (the formation of a hole in the digestive tract through which fluid can seep). A broad-spectrum antibiotic able to kill multiple bacterial strains will usually be used.

The antibiotics most commonly prescribed for Crohn's treatment include:

While oral antibiotics are typically used, severe cases may require intravenous antibiotics delivered in a hospital. Side effects include nausea, diarrhea, headache, dizziness, and a metallic taste in the mouth.

Corticosteroids

Corticosteroids, also known as steroids, temper the immune system as a whole and, by doing so, quickly reduce systemic (whole-body) inflammation. Corticosteroids are most commonly delivered in pill form but may also be prescribed in an intravenous or enema formulation for more severe cases.

Options include:

Corticosteroids are only recommended for short-term use.

Corticosterioids are not effective in preventing flares and are, therefore, rarely used for maintenance therapy. In addition, long-term use can cause undesirable and potentially serious side effects, including high blood pressure, acne, mood swings, cataracts, glaucoma, diabetes, and osteoporosis.

For these reasons, corticosteroids are prescribed at the lowest possible dosage for the shortest period of time. Frequent short-term use is also not recommended.

Immunomodulators

These drugs also temper the immune system as a whole but are taken on an ongoing basis. These drugs are used to treat a wide range of autoimmune and immune-modulated disorders and are typically indicated for people with Crohn’s disease who have not responded to aminosalicylates or corticosteroids. (Note: Corticosteroids and biologics are also potent modulators of the immune system, though they are not considered part of this drug class.)

Immunomodulators may be delivered by pill or intravenously. The choice of drug is based on the severity of your symptoms and the medications you have previously been exposed to. Oral formulations generally take longer to take effect than intravenous ones.

Among the approved options:

  • Imuran (azathioprine) is delivered in pill form and can take anywhere from three to six months before the benefits of treatment can be felt.
  • Purinethol (6-MP, mercaptopurine) is another oral formulation that may take up to six months to take effect.
  • Cyclosporine has a rapid onset of action (one to two weeks) but needs to be delivered intravenously at high doses. It is generally used until a slower-acting oral formulation can take full effect.
  • Prograf (tacrolimus) is delivered in pill form and is especially useful for people diagnosed with a fistula.
  • Methotrexate is only used when you cannot tolerate other immunomodulators. It is delivered in once-weekly intravenous infusions at a clinic.

A topical version of Prograf is also available to treat a rare ulcerative skin condition called pyoderma gangreosum, which sometimes develops in people with severe Crohn’s disease.

Side effects of immunomodulators include fatigue, nausea, vomiting, pancreatitis, kidney impairment, and an increased risk of infection.

Biologic Drugs

Biologics are usually large proteins produced, often with advanced molecular techniques, in living organisms. They have revolutionized the treatment of CD. Unlike immune modulators, biologics only affect a specific part of the immune response rather the whole. As a result, they provide a more targeted form of therapy with a shorter ramping-up time (typically four to six weeks). Biologics are delivered either by subcutaneous injection (under the skin) or intravenously every six to eight weeks.

Biologics are typically used in people with moderate to severe Crohn’s disease who have not responded to the other forms of treatment. Some doctors have begun to use biologics as first-line therapy in the hope that they may alter the course of the disease over the long term.

Generally speaking, biologics may be used sooner rather than later for people who were diagnosed at a younger age, who are being treated with frequent corticosteroids, and whose disease is limited to the small intestines.

The biologics can be broken down into three classes: integrin antagonists, interleukin inhibitors, and tumor necrosis factor (TNF) inhibitors. Each block a certain protein associated with inflammation.

The biologics commonly used to treat Crohn's disease include:

Common side effects include a headache, fatigue, stomach upset, diarrhea, upper respiratory tract infection, urinary tract infection, and rash.

Diet

Avoidance of any food or substance that can trigger or exacerbate symptoms is also key. This may involve an elimination diet, which entails methodically excluding and reintroducing certain foods to see how your body reacts. Doing so can not only help identify your specific dietary triggers but help you design a maintenance diet able to keep your disease in sustained remission. 

Low-Residue Diet

If you experience a sudden flare of symptoms, you will need to avoid placing any unnecessary stress on your digestive tract.

To this end, some doctors will endorse the use of a low-residue diet, particularly if you have been diagnosed with a stricture (narrowing) of the ileum (lower small intestine). A low-residue diet involves the omission of all foods that remain largely undigested and get "dragged along" in the stool.

These include foods such as corn hulls, seeds, whole grains, raw vegetables, beans, cured meats, tough meat, popcorn, and crunchy peanut butter.

Among some of the foods you can eat on a low-residue diet:

  • Applesauce
  • Chicken (roast or boiled without skin)
  • Crackers and plain cookies (such a vanilla wafers)
  • Cream of wheat
  • Fish
  • Fruit juice without pulp
  • Lean meats
  • Peanut butter (smooth)
  • Peeled soft fruit
  • Potato (skinless)
  • Well-cooked vegetables
  • White rice and pasta
  • White bread
  • Yogurt (smooth)

While a low-residue diet can offer significant relief during an acute flare, current research suggests that is it should only be used as a short-term solution. The prolonged absence of dietary fiber can actually have an inverse effect on people with Crohn’s disease, increasing both the frequency and severity of symptoms.

Liquid Diet and Bowel Rest

If your symptoms are especially severe, your doctor may recommend bowel rest for anywhere from a few days to several weeks. This may initially involve a liquid diet with the appropriate nutritional supplements to place as little stress on the bowel as possible. Bed rest may also be needed.

For the bowel rest period, your doctor will structure a list of high-calorie liquid foods, starting initially with clear liquids and nutritional shakes (either made with whey protein or non-dairy elemental formulas). The shakes are especially important as they ensure you are getting enough fiber, protein, and minerals as part of an increased-calorie diet. As the symptoms begin to ease, puréed and soft foods (like oatmeal and scrambled eggs) may gradually be introduced until you are able to tolerate solid foods again.

What Is a Full Liquid Diet and When Is It Used?

While bowel rest is ideally performed at home, hospitalization may be needed if you are unable to stomach food of any sort. In some cases, nutrition may need to be delivered either through an intravenous drip or a feeding tube inserted into your stomach. This, however, is not common.

Over-the-Counter Remedies

Over-the-counter (OTC) drugs may be used to treat mild pain and resolve moderate to severe bouts of diarrhea.

For pain, Tylenol (acetaminophen) can often provide ample pain relief in people with mild Crohn’s disease. On the other hand, nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin, Aleve (naproxen), and Advil (ibuprofen) should be avoided as they can often cause gastrointestinal bleeding and ulcers.

Diarrhea may be treated with a short course of antidiarrheal medications. There are two OTC drugs commonly recommended for short-term use:

Both work by slowing the contractions of the bowel, allowing the intestines to reabsorb some of the excess water. As effective as antidiarrheals are, you should only use them under the direction of a doctor. Overuse can lead to a rare but potentially life-threatening condition known as toxic megacolon, in which the colon suddenly dilates and is unable to contract, allowing gas and toxins to rapidly build up.

Vitamin Supplementation

People with Crohn's disease often develop vitamin or mineral deficiencies due to chronic gastrointestinal malabsorption. This is especially true with vitamin D, calcium, and vitamin B-12, each of which is absorbed in the small intestine.

To this end, a daily 800 IU supplement of vitamin D and a 1,500mg supplement of calcium may be used safely if a deficiency has been identified. Overuse of these supplements should be avoided as it may lead to kidney stones, abnormal heart rhythms, and even kidney damage.

People with a severe vitamin B-12 deficiency (usually those who have undergone bowel surgery; see below) may benefit from a monthly intramuscular injection or a once-weekly nasal spray of vitamin B-12.

Folic acid deficiency can also develop in people who take Azulfidine or methotrexate. A daily, 1mg folate supplement can usually counteract this deficit.

Speak with your doctor to determine which vitamin supplement or dosage is right for you.

Surgery

While surgery cannot cure Crohn's disease, it can treat complications and often help restore normal bowel function. Indications for surgery may include bowel obstruction, excessive bleeding, an abscess, intestinal rupture, and toxic megacolon.

Approximately 70 percent of people with Crohn's disease require surgery within 10 years of their initial diagnosis.

Among the surgical options:

  • Strictureplasty is a technique used to widen a narrowed intestinal passage (stricture). It involves only a lengthwise cut and suturing of the bowel, not removal. It can be performed on a stricture up to six inches (15 centimeters) in length.
  • Bowel resection involves the removal of a diseased portion of the intestine. It is often used when a stricture is too large to be treated with strictureplasty. Once the section of intestine is removed, the two ends are reattached in a procedure called anastomosis.
  • Colectomy involves the removal of a diseased portion of the colon. This surgery is usually reserved for severe cases and may either involve the removal of the entire colon (total colectomy) or only a part of the colon (partial colectomy).
  • Proctocolectomy involves the removal of both the colon and rectum. In some cases, the small intestine can be directly reattached to the anus in a procedure known as ileoanal anastomosis. In others, the intestine must be permanently redirected through a hole in the lower abdomen to allow waste to exit the body (known as an ileostomy).

    While these surgeries can often be extremely successful, half of the people who have one require another within three to five years. Oftentimes, the progression of the disease is such that a return of the disease, while not inevitable, is not unexpected. Age may also play a factor in disease recurrence, with some studies suggesting that younger people are at greater risk than older people.

    The one common factor for recurrence appears to be smoking. This may be explained in part by the way in which smoking narrows and hardens blood vessels throughout the body. When this occurs in damaged intestinal tissues, the reduced blood supply can make it harder to fight infection or deliver oxygen to vulnerable cells.

    As such, smoking cessation is considered a must for anyone who has undergone surgery for Crohn's disease or, frankly, anyone who is suffering symptoms of the disease.

    A number of studies have also suggested that the post-operative use of aminosalicylates (like Asacol), immune modulators (like Imuran), or TNF inhibitors (like Humira) may reduce the risk of recurrence.

    Complementary Alternative Medicine (CAM)

    People with Crohn's disease often support their therapy with complementary and alternative medicine (CAM), either to address nutritional deficiencies to or help ease symptoms.

    It is important to speak with your doctor about any supplement, traditional medicine, or herbal remedy you may be taking (or considering) to ensure that it does not interact with your prescribed drugs or inadvertently trigger a flare.

    As with diet, some approaches work better than others. Among the options frequently embraced by people with Crohn's disease:

    • Curcumin, a chemical found in turmeric, works similarly to NSAIDs but without the gastric side effects. A number of studies have shown curcumin to be effective in supporting immune modulator and aminosalicylate drugs. While there is no established dosage, a daily, two-gram dose is considered safe and beneficial. Side effects include stomach upset, nausea, dizziness, and diarrhea. Overuse may result in irregular heart rhythms.
    • Probiotics found in dietary supplements and certain foods like yogurt, sauerkraut, and miso can help restore the balance of "good" bacteria in your intestines. There is some evidence that the use of probiotics may help sustain remission in people with Crohn's disease. Side effects tend to be minimal and mainly involve mild gas and bloating.
    • Omega-3 fatty acids, found in fatty fish and fish oil supplements, are known to decrease systemic inflammation. Why the healthy fats can be beneficial to your diet, the evidence is split on whether supplementation can reduce the frequency or severity of Crohn's disease flares. In terms of side effects, mild nausea and bloating can sometimes occur.
    • Aloe vera juice is believed by some to have anti-inflammatory properties beneficial to treating Crohn's disease. To date, there has been no evidence to support this claim. Moreover, aloe vera has a laxative effect that may make your symptoms worse rather than better.

    It is important to remember that supplements, herbal remedies, and traditional medicines are not researched or regulated in the same way as pharmaceutical drugs. As such, you need to be wary of any curative claim that a manufacturer makes and approach anecdotal evidence and testimonials with extreme caution.

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