Crohn's Disease Treatments and Medications

The gastrointestinal tract, folded neatly within the abdomen, is about 30 feet long. That’s almost nearly three stories from one end to the other. Humans, to put it simply, have a whole lot of digestive systems, most of which—about 22 feet—are dedicated to the difficult, complex job of breaking down and absorbing nutrients. This might lend some perspective into Crohn’s disease, an often painful, sometimes debilitating inflammatory disease that can evolve the entire digestive system. It’s not an easy condition to have or to treat, but medical science is continually finding new ways to keep Crohn’s symptoms in check.

What is Crohn's disease?

Crohn’s disease (CD) is an inflammatory condition of the digestive tract. Along with ulcerative colitis (UC), Crohn’s disease is an inflammatory bowel disease (IBD) marked by inflammation caused by an inappropriate response by the immune system.

In ulcerative colitis, the inflammation is limited to the inner lining of the colon, with involvement of just the rectum in some cases, and the entire colon in other cases, and anywhere in between. The inflammation caused by Crohn’s disease, however, can spread deep into digestive system tissues, and the inflammatory response can unpredictably target any part of the digestive system from the mouth to the anus. The most common inflammation site is the lower part of the small intestine (ileum) and the colon. Still, the mouth, esophagus, upper small intestine, and anus can also be subject to inflammation. In half of all patients, Crohn’s affects both the small bowel and the colon.

Crohn’s disease (named after Dr. Burrill B. Crohn, who first described the disease in 1932), also called ileitis or regional enteritis, follows an unpredictable cycle of relapses and remissions. Each relapse can cause pain, diarrhea, malnutrition, and weight loss. Inflammatory relapses usually target specific areas of the intestines, leaving other areas untouched and healthy.

Over time, the damage Crohn’s inflicts on the intestinal tissues can lead to complications such as infections, abscesses, tunnels (fistulae), obstruction (stricturing), holes (perforations), and intestinal or colorectal cancer. Crohn’s patients are also at a higher risk for osteoporosis, anemia, blood clots, and depression. However, Crohn’s disease is only rarely fatal, but Crohn’s patients have a slightly higher mortality rate because of the risk of cancer or infections.

In 25-40% of all patients, Crohn’s also causes problems outside the digestive system, particularly the skin and eyes. One out of four patients first notices there’s a problem when the disease manifests outside the digestive system.

Researchers haven’t found the cause of Crohn’s disease. The major risk factor is genetic—one in five people diagnosed with Crohn’s has a relative with IBD. Scientists believe that active flare-ups are induced by an environmental trigger such as a microorganism, food, or some other substance that fires up the immune system. They have not been able to find specific triggers, but they have recognized risk factors such as smoking, oral contraceptives, NSAIDs (nonsteroidal anti-inflammatory drugs such as aspirin), and pregnancy.

The National Institutes of Health estimate that half a million people in the U.S. have Crohn’s disease. Most are first diagnosed with the condition between the ages of 15 and 35, but a surprisingly high number of people are first diagnosed in their 50’s or 60’s.

There is no cure for Crohn’s disease. However, several treatments can manage the symptoms of a flare-up, induce remission faster, and keep relapses at bay.

How is Crohn's disease diagnosed?

The diagnosis of Crohn’s disease is based on endoscopic examination of the small and large intestine, imaging, and biopsy. Most patients will first bring their problem to a general practitioner, but a gastroenterologist, a doctor who specializes in digestive system diseases, will perform the final diagnosis and management of the condition.

People usually first seek help during an active flare-up. The red flag symptoms of Crohn’s in its active phase are:

• Abdominal pain

• Diarrhea (particularly if it occurs at night)

• Reduced appetite

• Blood in the stools

• Lesions around the anus

• Weight loss

• Fatigue

• Fever

These symptoms can typically last for months if left untreated.

A medical history, physical exam, and lab tests are used to indicate if a diagnosis of Crohn’s is worth pursuing. A medical history can help identify the signs of Crohn’s, rule out other conditions, and identify any manifestations of the disease outside the digestive system. A physical examination and vital signs that will help the doctor determine how stable the patient is. Blood tests will be performed to test for infections, anemia, or nutritional deficiency. Fecal tests may be used to identify blood in the stool, rule out possible infections, and identify a substance, calprotectin, that typically signifies active Crohn’s disease.

The definitive method for diagnosing Crohn’s disease is to examine the tissues of the intestines through endoscopy/colonoscopy, CT or MRI imaging, and microscopic analysis of a tissue sample (biopsy).

To view the digestive tract, the doctor will either rely on a colonoscopy, enteroscopy, or capsule endoscopy. In a colonoscopy, the doctor inserts a tube into the colon to examine the lining of the colon for signs of Crohn’s. An endoscope is inserted through the mouth and allows the gastroenterologist to view the lining of the stomach and the first part of the small intestine. For capsule endoscopy, the patient swallows a pill-sized video camera. As it passes through the digestive tract, the doctor can view the lining of the stomach, small bowel, and colon.

Endoscopy also allows the doctor to remove a sample of diseased tissue for microscopic examination. A pathologist will examine this tissue sample for characteristic tissue and cellular signs of Crohn’s disease.

A CT scan or MRI may provide more detail about how the disease is affecting deeper tissues in the gastrointestinal system. Barium X-rays are seldom used, and usually only if the doctor suspects that the bowels are obstructed.

Crohn's disease treatment options

Crohn’s treatment has several goals: improving patients' symptoms and quality of life, reducing inflammation, and avoiding complications of long-standing, active Crohn's disease. Treatment will depend on the severity and extent of the condition, location, age of the patient, and the risk for complications.

Medications

Medications are the first-line treatment for controlling inflammation and preventing flare-ups. Some medications reduce inflammation by blocking the body’s ability to produce inflammatory substances. For more severe or unresponsive Crohn’s disease, medications that suppress the immune system will be used. Other medications will be used to treat symptoms such as diarrhea or complications such as anemia.

Diet therapy

Nutritional therapy may be used during flare-ups to help manage symptoms and avoid malnutrition. Therapy may include a special diet, dietary supplements, or intravenous feeding.

Surgery

Traditionally, over 50% of Crohns patients will need surgery in their lifetime, however with newer medications out for treatment, this rate has been decreasing. Most will be due to complications such as an abscess, fistula, or perforation. Some, however, will have a diseased part of their small intestine or colon removed. A strictureplasty may be used to widen areas in the intestine that are obstructed.

Lifestyle changes

Lifestyle changes will be required, particularly dietary changes, mostly focused on increasing nutrition, taking supplements, and avoiding foods that worsen symptoms.

Support

Depression, anxiety, poor self-image, low quality of life, and relationship problems are common complications of Crohn’s disease. Support groups and counseling are important foundations of living with the condition.

Crohn's disease medications

Medications are used to induce remission and reduce symptoms during an active flare and then prevent relapse in the remission phase.

Aminosalicylates

The first-line therapy for Crohn’s flare-ups in patients with mild to moderate Crohn’s disease is aminosalicylates. The exact mechanism of action of these medications is not entirely known. However, they appear to prevent the immune system's production at the level of the intestinal lining. They can be used both during a relapse and taken regularly during remission to prevent relapse. The most commonly used are sulfasalazine and mesalamine, but a doctor may prescribe an alternative such as balsalazide. Both mesalamine and sulfasalazine are taken as tablets, but mesalamine can be delivered directly to the rectum or colon as a suppository or enema.

Corticosteroids

Corticosteroids are used in the short-term to rapidly alleviate symptoms and induce remission of active Crohn’s disease in patients with moderate to severe Crohn’s disease. Most patients will be given oral corticosteroids, but steroids can also be delivered as a suppository, rectal foam, or enema. Prednisone is the drug of choice, but a newer generation of budesonide has far fewer side effects, as it is almost exclusively delivered to the lining of the intestines and not absorbed into the bloodstream.

Immunosuppressants (immunomodulators)

If corticosteroids do not resolve symptoms or the patient is unable to take steroids, guidelines call for using off-label drugs that suppress the immune system: thiopurines (azathioprine or mercaptopurine) or methotrexate. Thiopurines take longer to produce remission, so they are mainly used to maintain remission, while methotrexate is another option when corticosteroids don't work. Tacrolimus and cyclosporine are other off-label immunosuppressants that might be used to treat Crohn’s flare-ups. Tacrolimus can also be applied topically to treat Crohn’s flare-ups in the mouth or reactive skin ulcers due to Crohn’s.

Monoclonal antibodies

When corticosteroids and immunosuppressants fail to resolve symptoms, doctors turn to antibodies, also called “biologics.” The immune system uses many proteins to “signal” instructions or carry out important functions. Monoclonal antibodies are designed to “glue” to these substances, effectively shutting them down. These medications, in general, produce symptom improvement in roughly 50-70% of patients and remission in 40-50%.

Biologics are administered as injections or intravenous infusions. They are usually given every few weeks, up to every eight weeks. If a biologic is discontinued during remission, the body may develop immunity to it, making it ineffective during the next flare-up.

Monoclonal antibodies are classified by the protein they attach to and shut down. The first line of antibody therapy for Crohn’s disease is anti-TNF (tumor necrosis factor) antibodies. They shut down the protein that signals immune cells to go on the attack. These include Remicade (infliximab), Humira (adalimumab), or Cimzia (certolizumab pegol). Unlike the immunomodulators, the anti-TNF antibodies work fairly quickly. Interestingly, they have been shown to be even more effective when combined with a thiopurine, however this can also increase the risk of infections and cancer.

Entyvio (vedolizumab) and Tysabri (natalizumab) are the next line of therapies. They dial back the immune response by attaching to integrin, a protein that white blood cells use to glue themselves to the lining of a blood vessel to exit the bloodstream. As a result, white blood cells aren’t able to migrate out of blood vessels and congregate around intestinal tissues to cause damage.

Finally, another drug therapy for Crohn’s is Stelara (ustekinumab), an antibody that targets interleukin, a molecule that signals immune cells—leukocytes—to start dividing and produce more leukocytes.

Other medications

Antibiotics such as metronidazole or ciprofloxacin are sometimes used to treat Crohn's flare-ups, but the data regarding their use in Crohn's disease is equivocal. However, intestinal infections, abscesses, fistulae, and Clostridium difficile infections are common complications of Crohn’s disease, so antibiotics are a normal part of living with the condition. Other medications used to treat complications include pain relievers, antidiarrheal medications, and iron, B12, or other supplements.

What is the best medication for Crohn's disease?

Healthcare professionals follow guidelines in prescribing medications for Crohn’s disease. They will choose drugs based on the severity of the condition, other illnesses, the patient’s history with Crohn’s disease medications, and their tolerance for side effects. Unfortunately, most drugs used to treat Crohn’s are not successful with all patients. There is, then, no “best” medication for Crohn’s disease. Ultimately, the best medications are the ones that calm or prevent flare-ups with the least harmful side effects.

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Best medications for Crohn’s disease