In Inflammatory Bowel Disease, Treat The Disease, Not The Symptoms

The two major inflammatory bowel diseases, Crohn disease and ulcerative colitis, tend to have serious, even deadly, long-term consequences.

Crohn disease is a condition that tends to "come and go." Sometimes symptoms are worse, sometimes symptoms are better, but crisis is inevitable. By the time people have had Crohn disease for 15 years, there is a 70 percent chance they will have gone through a crisis requiring surgical removal of part of the colon. 

Crohn disease can cause ulcers that "skip" along the entire digestive tract, but ulcerative colitis is focused in the bowel. Ulcerative colitis is also a disease with a dismal long-term prognosis. From 40 to 60 percent of people diagnosed with ulcerative colitis eventually develop a condition called pouchitis, characterized by diarrhea, incontinence, chronic fatigue, and fever, 18 percent in the first year after diagnosis. If the condition is not handled properly, it can, in about 2 percent of cases, there can be toxic megacolon, which causes abdominal bloating, intense pain, rapid heartbeat with lower blood pressure, and general symptoms of toxic shock. Usually megacolon occurs after a trigger, such as taking opiate pain killers, receiving a barium enema, or low potassium levels, which can be induced by inappropriately prescribed blood pressure medications. Sometimes the only treatment for toxic megacolon is a colectomy, surgical removal of the colon. There is also a 1/2 to 1 percent annual risk of developing colon cancer even when the disease is well-controlled.

Treatment of Inflammatory Bowel Disease Usually Focuses on Symptoms

Because Crohn disease and ulcerative colitis are extremely unpleasant, patients demand and doctors provide short-term relief. Nearly everyone who has either form of inflammatory bowel disease gets graduated, "step-wise" treatment.

• Step I involves treatment with anti-inflammatory drugs in the aminosalicylate class. Chemically similar to Aspirin, these medications balsalazide (Colazal), Mesalamine (Apriso, Asacol, Lialda, Pentasa), olsalazine (Dipentum), and sulfasalazine (Azulfidine) are taken as oral medications, enemas, or suppositories. Also at this stage the doctor usually prescribes a high-potency probiotic formula.
• Step IA is treatment with selected antibiotics, usually Ciprofloxacin and metronizadole. These treatments tend to be more helpful in Crohn disease than in ulcerative colitis. The downside of antibiotic treatment is that it can kill the "good bugs" and allow a serious infection such as Clostridium dificile to start. The benefits of antibiotic therapy often do not outweigh its side effects.

READ Inflammatory Bowel Disease (IBD)

• Step II is treatment with steroid drugs. Medications such as prednisone, dexamethasone, and Hydrocortisone relieve inflammation of the bowel, but weaken the immune system. They can cause death of bone, peptic ulcers, cataracts, and psychiatric symptoms. Usually the doctor reduces dosage once bowel inflammation is under control.
• Step III involves weakening the immune system to limit inflammation. One of the most popular medications in the United States are adalimumab (Humira) or infliximab (Remicade), which are biologically engineered antibodies that bind to TNF-alpha, which causes the inflammation of the bowel. One serious downside to treatment with Humira or Remicade is that every dose costs between $1300 and $2500. Another serious downside is that combining Remicade with other treatments used at this stage (azathioprine or 6-mercaptopurine) greatly increases the risk of lymphoma.

If these treatments don't work, then doctors may try nicotine patches, enemas with a natural anti-inflammatory called butyric acid, or the anticoagulant heparin. The problem is that patients and doctors alike become focused on treating symptoms without treating the underlying cause.

Treating the Causes Of Inflammatory Bowel Disease

As important as it is to ease the discomfort of inflammatory bowel disease, mucosal healing is even more important over the long run. When ulcers in the lining of the digestive tract, there will be:

• Lower risk of developing a fistula, a second opening of the bowel through the skin.
• Lower need for steroid anti-inflammatory medications, which can cause osteoporosis, weakened immunity, weight gain, and psychiatric issues.
• Fewer relapses of pouchitis, diarrhea, and abdominal pain.
• Reduced risk of needing a colectomy.

Experts generally define healing as one year (or 50 weeks) without serious symptoms. It is not necessary to be absolutely ulcer-free to be declared in remission from inflammatory bowel disease; but there should be no disabling symptoms for 50 weeks or more. Unfortunately, part of making sure of mucosal healing is increased use of colonoscopy to monitor progress. On the whole, however, colonoscopy is less unpleasant than the day to day symptoms of the active disease.

Which treatments are most likely to induce a long-term state of mucosal healing? There is general agreement that steroids do not induce healing. They only relieve pain and inflammation in the short term. Also, different sets of treatments may be needed for Crohn disease and ulcerative colitis.

In Crohn disease, mucosal healing may be achieved by:

• Steroid drugs, or
• Adalimumab (Humira), or
• Infliximab (Remicade).

The medication Mesalamine may relieve symptoms in a small number of people who have Crohn disease, but it will not bring about mucosal healing. Remicade is more likely than Humira to sustain mucosal healing.

In ulcerative colitis, mucosal healing is much easier in mild to moderate disease than in severe, active disease:

• Daily administration of an extended-release form of Mesalamine (Apriso, Asacol, Canasa, Lialda, Pentasa, or Rowasa), if the condition is mild to moderate. Generally, higher doses are more effective than lower doses. As many as 80 percent of users achieve mucosal healing in just six weeks.
• In ulcerative colitis patients who are dependent on steroid medications, azothioprine (AZA) may lead to mucosal healing and discontinuation of the steroids. However, AZA, like steroids, weakens the immune system.
• Moderate to severe ulcerative colitis may be brought into remission about 25 percent of the time by a year's administration of adalimumab (Humira).
• Up to 87 percent of patients have achieved remission during a 12-week clinical trial with tacrolimus (Hecoria), although sudden hair loss was a possible side effect.

READ Helicobacter pylori: The Bacteria that Cause Ulcers

Different medications are required in ulcerative colitis:

• In one study, no patients on continuous adulimumab (Humira) treatment for a year achieved mucosal healing.
• In another study, 43 percent of patients who received both inflixumab (Remicade) and azothioprine (AZA) achieved mucosal healing in 26 weeks. Continuing treatment with inflixumab sustained mucosal healing once it was achieved.

There are a number of reasons people who have inflammatory bowel disease are well served to strive for mucosal healing. There is lower risk of formation of fistula, a second opening of the bowel through the skin. There is lower risk of colorectal cancer. There is lower risk of megacolon, which may necessitate removal of the colon. Achieving stability with inflammatory bowel disease seems to require taking an expensive monoclonal antibody, but there are programs to help with the cost of the drug and there are ways to manage the immune suppression caused by the disease. Don't settle just for treatment of symptoms. Seek long-term solutions that maximize quality of life.