Crohn's Disease: Your Treatment Options

Given the chronic nature of the disease, treatment for Crohn’s disease has three main goals:

• To relieve symptoms, also called achieving remission
• To prevent symptom flare-ups, also called maintaining remission
• To improve quality of life

Because Crohn’s is unpredictable, treatment must be customized to each person. There is no “one way” to treat Crohn’s disease. Treatment often involves a combination of therapies and approaches that may change over time as the disease progresses. How the disease is treated depends on a number of factors:

• Where the disease is found in the GI tract
• What complications you may have
• How severe the disease is
• What past treatments you have received and how you responded to them

There are essentially two phases of treatment for Crohn’s disease. The first is to control inflammation and relieve symptoms. This allows the intestines to heal. Then once symptoms have gone into remission, treatment is aimed at keeping your symptoms from returning.

Medications for Crohn’s Disease

Many of the medications used for Crohn's are used both to ease symptoms and to maintain remission once symptoms are under control, although at different dosages depending on the desired goal. There are five main drug classes used to treat Crohn’s disease.

Antibiotics may be used both to treat symptoms of Crohn’s disease and as a long-term therapy to help treat abscesses and fistulas.

• How given: orally, by mouth, or intravenously (IV).
• How they work: Antibiotics are very effective at killing bacteria that cause infections. Some researchers also believe they may help suppress the immune system. Currently, studies are being done to determine the effectiveness of using antibiotics to help control the disease.
• Possible side effects: Nausea, vomiting, metallic taste, diarrhea, stomach pain, headache, insomnia, discolored urine, and nervousness.

Aminosalicylates (5-ASA medications) are a class of anti-inflammatory drugs used to treat people with mild to moderate Crohn’s disease. They are aspirin-like compounds that contain 5-aminosalicylic acid (5-ASA).

• How given: orally, by mouth, or rectally, as an enema or a suppository
• How they work: These drugs help control inflammation directly at the lining of the GI tract. They also work throughout the body to interfere with the inflammatory process. Aminosalicylates are used both to help control symptoms and to maintain remission of the disease.
• Possible side effects: headaches, rash, nausea, respiratory infection, hair loss, joint or muscle pain, diarrhea, stomach pain, vomiting, and loss of appetite. Men using one type of 5-ASA drug may experience infertility, although this goes away after the drug is stopped.

Corticosteroids are powerful and fast-acting drugs used for short-term treatment of symptom flares in people with moderate to severe Crohn’s disease. People receiving these drugs often see an improvement in symptoms within a few days of taking them. Because of the risk for significant side effects, corticosteroids are not used for maintenance therapy.

About half the time, these drugs can cause a recurrence of symptoms when a person stops taking them. For this reason, they are given at the lowest dosage for the shortest amount of time.

There is a newer type of corticosteroid that targets just the intestine rather than the entire body. This drug has fewer side effects and is being used to treat people with mild to moderate Crohn’s.

• How given: Orally by mouth, as an IV, or rectally as enemas or suppositories.
• How they work: by interfering with the body’s ability to start and maintain inflammation. They also help suppress the immune system.
• Possible side effects: high blood pressure, high blood sugar, weight gain, acne, mood swings, insomnia, increased risk of infection, facial hair, weakened bones (osteoporosis), dizziness, depression, anxiety, psychiatric symptoms (psychosis, or losing touch with reality), bulging eyes, rounded face, upset stomach.

Immunomodulators, drugs that suppress the immune system, are usedfor people with moderate to severe Crohn’s disease who:

• Have not responded to treatment with aminosalicylates or corticosteroids
• Often need treatment with corticosteroids and/or who cannot come off corticosteroids without developing a flare-up of symptoms
• Have side effects from corticosteroids

Immunomodulators are often used with corticosteroids to help improve the body’s response to medication during a flare-up of the disease. They help reduce dependency on corticosteroids. They also help maintain remission. Immunomodulators can take as long as three months to work or longer.

• How given: most often by mouth, but they can also be used topically or by injection.
• How they work: these medicines modify the body’s immune system response to help prevent ongoing inflammation.
• Possible side effects: nausea, vomiting, diarrhea, loss of appetite, mouth sores, headache, rash, fever, back or joint pain, increased risk of infection, acne, drowsiness, insomnia, burning or tingling of hands or feet, itching, stomach pain, dizziness, and increased facial hair growth.

Biologics are the newest class of therapies used to treat people with moderate to severe Crohn’s disease. They are used in people who have not responded to treatment with aminosalicylates, antibiotics, corticosteroids, or immunomodulators.

• How given: injection under the skin or by an IV
• How they work: These therapies are engineered to target specific proteins involved in inflammation. Because they don’t affect the entire immune system, they tend to have fewer side effects. However, certain side effects can be serious.

Possible side effects: Redness, swelling, itching, pain, rash, or bruising at the injection site. Other side effects include upper respiratory or sinus infections, headache, nausea, urinary tract infections, depression, tiredness, diarrhea, stomach pain, joint pain, sore throat, back pain, and weight gain. More serious side effects include an increased risk of serious infections and lymphoma, cancer of the lymphatic system. Other serious side effects include heart failure, serious allergic reactions, a lupus-like syndrome, blood disorders, and a nerve condition that causes weakness and numbness.

Communication: Key to Your Crohn's Treatment

To help ensure that your treatment works effectively, it’s very important to take all medications as directed by your doctor. You should never stop taking a medication without consulting your doctor as it could cause symptoms to return.

Because some drugs may cause more serious side effects, your doctor may monitor you as you undergo treatment. So be sure you go to all follow-up doctor appointments and have all recommended laboratory tests.

If you have any questions about your treatment options or concerns about side effects, be sure to discuss these with your doctor. “A patient and physician have to weigh the risks and benefits of each treatment together based on the patient’s comfort level and the doctor’s expertise and experience,” says Edward Loftus, MD, professor of medicine at the Mayo Clinic in Rochester, Minn.

Surgery for Crohn’s Disease

When serious complications develop, medications alone no longer control Crohn’s disease or no longer work as effectively, your doctor may recommend surgery. It can be an important option for long-term relief of symptoms.

Not everyone with Crohn’s disease will need surgery, but many do. “Sixty to 80 percent of people with Crohn’s will need at least one surgery. Half of those people will need a second surgery. The average is about one to two surgeries in a person’s lifetime,” Loftus says.

In people with Crohn’s disease, surgery is used to:

• Widen a portion of the intestine that has become narrowed, also called a stricture. This procedure is called a strictureplasty.
• Remove a diseased section of the intestine or to treat a fistula. After the section is removed, the two ends of healthy intestine are sewn back together.  This is called a resection.
• Remove the entire rectum and colon, or just the colon. If only the colon is removed, called a colectomy, the end of the small intestine is connected to the end of the rectum, which allows the person to have regular bowel movements. If both the colon and rectum are removed, called a proctocolectomy, the end of the small intestine  is connected to a hole in the abdomen wall in a procedure called an ileostomy. The hole itself is called a stoma. Waste passes through the stoma and is collected in an external bag, which needs to be emptied throughout the day. Clothing easily hides the bag, so no one can tell that you are wearing one.
• Drain an abscess.

Your doctor will recommend the type of procedure that will effectively treat your symptoms and any complications while preserving as much of your intestine as possible.

It’s important to understand that with Crohn’s disease, surgery cannot cure the disease, even when the inflamed part of the intestine is removed. In fact, about 50 percent of people with Crohn’s disease will see the disease come back to another part of the intestine within 5 years after surgery. However, having surgery can help relieve symptoms for years once medications are no longer effective.  

Taking immunomodulators or aminosalicylates after surgery may help reduce the chance of the disease recurring. If the disease does return, it can often be treated with medication.

What to Do If You Need Surgery for Crohn's

If you face the prospect of having surgery, it’s important to give it your full consideration if your doctor recommends it. Surgery is not just a last-ditch effort to control the disease. It can be an important part of your treatment plan and greatly help improve the quality of your life. Here are some things you can do to help ease your concerns:

• Learn all you can about what type of surgery is recommended, why it is recommended, and what your other treatment options may be.
• Learn what to expect before, during, and after surgery.
• Ask your doctor what you can and can’t expect as a result of the surgery.
• Ask for a second opinion. You should not hesitate to ask for another opinion if you want one.
• Talk with people who have had the same type of surgery to find out about their experiences.

Once you’ve considered your options, you can make an informed decision. Surgery should not be taken lightly, however, it may be the best option to help relieve your symptoms and help you live a fuller life.

Maintenance Therapy for Crohn's

After you have entered remission, you will start maintenance therapy. The goal is to keep your symptoms from returning for as long as possible. Many of the same drugs used to help control flares are also used for maintenance therapy. Which medication or combination of medications your doctor recommends will depend on:

• What your symptoms are
• Where your Crohn’s disease is located
• Whether you experience any side effects
• Whether you have had surgery

Antibiotics, 5-ASA medications, immunomodulators, and biologics are all used to help maintain remission.

It is much easier to stay in remission than it is to get the disease under control in the first place. Here are some steps you can take to help maintenance therapy work for as long as possible:

• Always take your medication as directed by your doctor. Don’t skip doses or take less than recommended. If cost is a factor, talk with your doctor. He may be able to put you in touch with programs that offer free or discounted prescription medications.
• If you smoke, join a smoking cessation program. Smoking makes Crohn’s more active and may prevent remissions.
• Avoid taking aspirin and nonsteroidal anti-inflammatory drugs such as ibuprofen (Advil, Motrin) and naproxen (Aleve), as they can irritate the stomach and trigger disease flares. Don’t take any other prescription medication, OTC drug, nutritional supplement, or natural remedy without first talking with your doctor.

To help manage occasional bouts of cramping, diarrhea, or joint pain, your doctor may suggest the use of certain over-the counter drugs:

• Medications to stop diarrhea
• Acetaminophen (Tylenol)

However, because these drugs can hide symptoms of a disease flare, it’s important to consult your doctor before taking them.

Crohn's: Looking to the Future

“Over the last decade, treatment improved dramatically with the introduction of biologics. That forward progression has slowed somewhat in the last few years, but there are a lot of hopeful new treatments in the pipeline. I think we will continue to find biologics that are quite effective. And in the near future, we are refining the use of current therapies to more effectively treat Crohn’s disease,” says Joshua Korzenik, MD, assistant professor of medicine at Harvard Medical School. Korzenik is the director for the Crohn’s and Colitis Center at Massachusetts General Hospital in Boston.

There is no question that living with Crohn’s disease is a challenge. But the future looks bright as researchers from all over the world focus on understanding more about this complex and mystifying condition.