Crohn's Disease Treatments Management

What is the best acute and chronic management of Crohn's Disease?

In-hospital continuous infusion of either hydrocortisone 300 mg per day or ACTH (adrenocortico-tropic hormone) 120 units per day is the treatment of choice for induction of remission in patients with acute, severe Crohn's disease. Dehydration, electrolyte abnormalities, anemia, and sepsis should be treated concomitantly.

Patients are encouraged to maintain as normal a diet as is tolerated unless there is any sign of intestinal obstruction. In patients with partial or complete intestinal obstruction, we recommend placement of a long intestinal tube. Daily fiat and upright radiographs are obtained until resolution of obstruction is complete.

Surgical consultation is recommended. Broad-spectrum antibiotics are reserved for patients with signs of sepsis associated with an intra-abdominal or perirectal abscess or fistula. Surgical drainage in combination with sitz baths is often required for resolution of a painful perirectal abscess. Elemental or parenteral hyperalimentation is implemented only in patients who are unable to maintain adequate oral nutrition or in patients who are moderately to severely malnourished, with hypoalbuminemia. We recommend avoiding the use of narcotic analgesics and antidiarrheal agents, as these may prolong response tune and frequently induce patient dependence on these medications.

For maintenance therapy in Crohn's disease, sulfasalazine and a number of its 5-aminosalicylic acid ( 5-ASA) split products are currently the mainstay for initial therapy. The 5-ASA oral compounds currently available in the United States include olsalazine (Dipentum) and mesalamine (Asacol). Mesalamine is also available as a retention enema (Rowasa) and as a suppository (Rowasa).

Mesalamine (Pentasa) has been used in Europe and is now available in the United States. The 5-ASA compounds appear to be at least as effective as sulfasalazine in treating Crohn's disease. Their major advantage is a relative lack of the dose-related side effects that frequently limit the usefulness of sulfasalazine. Among the side effects are nausea, vomiting, anorexia, fever, skin rashes, headache, and skin discoloration. The most common side effects of mesalamine and olsalazine are nephrotoxicity and diarrhea, respectively.

Olsalazine is of less value in Crohn's disease than in ulcerative colitis because it must be split by colonic bacteria to release the effective therapeutic agent. In contrast, mesalamine should be favored in Crohn's disease, where release can be anticipated in the small bowel and right colon. One drawback to the use of the newer 5-ASA drugs is their significantly higher cost compared with sulfasalazine.

Dosing of these medications should be titrated to patient response and tolerance. The usual oral dosage range for sulfasalazine is 2 to 6 g/day, 500 mg to 1 g/day for olsalazine, and 1.6 to 3.2 g/day for mesalamine. It must be noted that sulfasalazine and the 5-ASA compounds are also used in the treatment of acute-onset, mild-to-moderate Crohn's disease.

Are immunosuppressives part of Crohn's Disease treatment?

The immunosuppressive agents 6-mercaptopurine (Purinethol) and azathioprine (Imuran) are effective in inducing and maintaining remission in Crohn's disease refractory to corticosteroids and other conventional medical therapies. In the landmark study by Korelitz and associates, 6-mercaptopurine successfully induced and maintained remission in 68 percent of patients with severe refractory Crohn's disease, compared with eight percent in the placebo group.

The mean response time was 3.1 months, a delay that may limit its usefulness in patients with severe disease, although steroids may buy time until the drug becomes effective. The agent is also effective in enteric and perianal fistulae, which are chronic complications of Crohn's disease.

The most common toxic effect of these drugs is leukopenia, a condition that resolves when the drug is temporarily discontinued. Significant bone marrow suppression was noted in only two percent of 396 patients with inflammatory bowel disease treated with 6-mercaptopurine. Other toxic effects that have been reported include pancreatitis, hepatitis, hypersensitivity reactions, infections secondary to immune suppression, and late-occurring neoplasia.[ Methotrexate and cyclosporine are also promising immunosuppressive agents.

Last updated Jan 4/07