Treating Crohn’s disease

The main goal of treatment in Crohn's disease is to prevent inflammation.

Examples of medicines indicated for Crohn’s disease are as follows:

• Steroids: These reduce total body inflammation, but have numerous side effects including a puffy face, excessive facial hair, night sweats, insomnia and hyperactivity. More serious side effects include high blood pressure, diabetes, osteoporosis, bone fractures, cataracts, glaucoma and an increased chance of infection. For example, prednisone is often used to elicit remission over 3-4 months.

• Aminosalicylates: These drugs suppress inflammation in the intestine and joints. Examples include mesalazine, olsalazine, sulphalazine and balsalazide.

• Immunosuppressants: These suppress the immune system and reduce levels of inflammation. They’re often used in people who relapse when they come off steroids. Examples include azathioprine, mercaptopurine, methotrexate, mycophenolate mofetil, ciclosporin and tacrolimus.

• Antibiotics: These kill bacteria in irritated areas of the bowel. They may also be indicated when abscesses and fistulas are present. Examples include metronidazole and ciprofloxacin.

• Biologics: These are monoclonal antibodies that target the immune system – specifically tumour necrosis factor (TNF). These medications block the effect of TNF and are, for this reason, also called anti-TNF drugs. TNF is a substance made by immune system cells that causes inflammation. TNF inhibitors have potentially very serious side effects. They’re generally prescribed for moderate to severe Crohn's disease that isn’t responding to other therapies. Infliximab (Remicade) and adalimumab (Humira) are two TNF inhibitors.

• Anti-diarrhoeal medications: For example, lopermide may be helpful when diarrhoea is present without infection. Anti-diarrhoeal medications work by slowing down the contractions (muscle movements) in the gut, so food moves more slowly. 

• Bile salt binders such as colestyramine bind to bile salts that may enter the colon in excess and cause diarrhoea if the ileum is affected or removed by surgery.

• Laxatives such as Movicol may help relieve constipation by increasing the amount of water in the large bowel and making stools softer and easier to pass.

• Bulking agents such as Fybogel are made from plant fibre and make stools easier to pass. However, they should be avoided if you have a stricture (narrowing of the bowel).

• Painkillers (e.g. paracetamol) can be used for pain management. Steer clear of non-steroidal anti-inflammatory drugs, as these may worsen Crohn’s disease.

• Anti-spasmodics can reduce painful cramps and spasms by relaxing muscles. They’re most commonly recommended for people with IBS-like symptoms. However, caution must be used if there’s a risk of developing an obstruction.

Bowel rest
If the symptoms of Crohn's disease become severe, bowel rest may be indicated. This gives your gut a chance to heal. During this period, only clear liquids are allowed. However, depending on the severity of your symptoms, it could also mean not taking anything by mouth. If this is the case, nutrition will be given through a major central vein (total parental nutrition).

Surgery
Due to the advancements in standard medical treatment (discovery of biologics etc.) extensive gut resections (removal of large sections of the intestine) are now less common.

However, up to 8 out of 10 people with Crohn’s disease will still need surgery at some point in their lives as a means to better manage their symptoms or if complications are present (e.g. obstruction, fistula). 

The two most common surgeries that are indicated are:

• Stricturoplasty (strictureplasty): During this procedure, the surgeon widens the narrowed part of the gut.
• Resection: This involves the removal of severely inflamed parts of the intestine that may have a blockage or a fistula. The non-diseased ends are then joined together again.

If you suffer from Crohn’s disease in the colon (large bowel), it may be necessary to remove the whole colon and perhaps even the rectum. The following surgeries may be indicated: 

• Proctocolectomy and ileostomy: The whole colon and rectum is removed, and the end of the small intestine is brought out through an opening in the wall of the abdomen. A stoma bag is fitted onto the opening to collect the waste that would have previously gone into the colon. The bag can be emptied or changed when necessary. 
• Ileo-rectal anastomosis: The whole of the colon is removed but not the rectum. Therefore, the ileum (the last part of the small intestine) is joined to the upper end of the rectum. This is only possible if the rectum hasn’t been affected.
• Partial colectomy and colostomy: If only a section of the colon is affected, your surgeon may only remove the damaged section and rejoin the healthy sections of the bowel or create a stoma (opening). This is usually done on the lower left side of the abdomen and is known as a colostomy.
• Temporary stoma (ileostomy or colostomy): Stomas can be temporary and used to divert the waste produced from digestion away from the inflamed intestine. This gives the intestines time to heal after which the procedure is reversed. 

Emerging medical therapy: Vedolizumab
Vedolizumab, an intravenous antibody medication, offers new hope for people who suffer from inflammatory bowel disease (IBD), say researchers who led two clinical trials, the results of which were published in the New England Journal of Medicine. The treatment resulted in remission of IBD and allowed patients to stop taking prednisone, a drug with ample side effects used to treat both diseases (Crohn’s disease and ulcerative colitis).

The two trials showed very encouraging results for people suffering from moderate to severe Crohn's disease and ulcerative colitis when conventional therapy such as steroids, immune suppressive drugs and other drugs failed, said William Sandborn of the UC San Diego School of Medicine, who led the Crohn's study. The findings could potentially lead to a new drug therapy.

Vedolizumab blocks immune system cells that release proteins called cytokines that trigger inflammation, causing diarrhoea and tissue damage in the small intestine and colon. The medication could help people with Crohn’s disease and ulcerative colitis avoid the weight gain, nausea and headaches associated with other treatments. Patients could also potentially forgo the steroids and immunosuppressive medication that put them at risk for infection.

Gene therapy 
Crohn's disease appears to have at least two distinct genetic subtypes, which could explain why the condition is so hard to treat, a 2016 study suggests.

"The one-treatment-fits-all approach doesn't seem to be working for Crohn's patients," said Dr Shehzad Sheikh, study co-author and assistant professor in the departments of medicine and genetics at the University of North Carolina’s School of Medicine. "It's plausible that this is because only a subset of patients has the type of disease that responds to standard therapy, whereas, for the rest of the patients, we're really not hitting the right targets," Sheikh said in a university news release.

For the study, Sheikh and his team analysed colon tissue samples from 21 Crohn's patients and discovered at least two separate genetic subtypes of the disease. Each had its own pattern of gene expression and mix of clinical characteristics, the researchers reported in the journal Gut. These differences existed independently of patients' ages or treatment histories, Sheikh said.

The researchers said they believe the finding could lead to more effective treatments for Crohn's. "We hope one day to be able to test Crohn's patients for the subtype of the disease they have, and thus determine which treatment should work best," Sheikh said.

Vitamin D
Vitamin D deficiency is common among people with Crohn's disease, and a randomised, double blind, placebo-controlled study found that vitamin D supplementation corresponded to significant relief of symptoms. 

The study found that, after three months of taking 2000 IU of vitamin D per day, patients' muscle strength, measured by hand-grip, was significantly higher in both dominant and non-dominant hands compared to those taking placebo. Study participants also reported significantly less general, physical and mental fatigue – and a higher quality of life – when levels of vitamin D were 75 nanomoles per litre or more.

Diet
There’s no clear evidence that any food directly causes or improves Crohn’s disease, but many people with Crohn’s disease say that certain foods seem to trigger their symptoms. 

To ensure that your diet remains healthy and well-balanced, it’s important to get advice from your doctor or dietitian before making any major changes. It may also help to keep a food diary to track what you’ve eaten and if your symptoms change. 

The following dietary changes may assist in symptom control: 

• Avoid carbonated beverages, including sparkling water. 
• Talk to a dietitian about your fibre intake as you may need to avoid foods such as popcorn, vegetable skins, tough meat and nuts (especially if you have a stricture).
• Reduce the intake of gas-forming foods like beans, broccoli and cauliflower. 

Practise the following good habits:

• Drink more liquids.
• Eat smaller, more frequent meals throughout the day.
• Chew your food thoroughly.

Some people with Crohn’s disease report that the following dietary changes help them to manage their symptoms: 

• Limiting dairy products, especially where diarrhoea, abdominal pain and gas are the main symptoms of concern. Some people with IBD are lactose intolerant (i.e. the gut struggles to digest lactose). Work with your healthcare professional to assess whether or not you’re lactose intolerant (a hydrogen breath test may be indicated) and to ensure that your daily intake includes enough calcium from other food sources. You may have to supplement your diet to ensure good bone health.
• Consuming lower-fat foods. This could be especially helpful if you have Crohn's disease of the small intestine as you may not be able to digest or absorb fat normally. Avoid high-fat foods such as cookies, pastries, butter, margarine, cream sauces and fried foods.
• Avoiding common food triggers (e.g. spicy food, alcohol and caffeine). 

If you have Crohn’s disease, you’re at risk of vitamin deficiencies, especially if you have trouble absorbing nutrients due to inflammation in the small intestine. The following table outlines the common deficiencies associated with the disease: 

Consult with a registered dietitian and ask him or her to compile a personalised eating plan for you, based on your individual gut triggers. The eating plan will help you to manage your symptoms and your nutritional intake.

It’s also important to maintain your weightduring flare-ups, as weight loss is an indicator of poor nutritional intake. If you’re losing weight, discuss this with your healthcare team.

The following could help you gain weight after a flare-up: 

• Eat small, frequent meals throughout the day.
• Eat enough protein-rich foods.
• Eat energy and nutrient-dense foods. 
• Drink nutritional supplements or fluids that are nutrient dense (e.g. soup) as opposed to juice, tea or coffee. 
  

The low-FODMAP diet
The low-FODMAP diet (a diet low in fermentable carbohydrates) has mostly been used to address irritable bowel syndrome (IBS) symptoms in study participants. Some research has, however, suggested that certain people with inactive inflammatory bowel disease (IBD), who suffer from IBS-like symptoms, may benefit from following a low-FODMAP diet.

But for those with active IBD it hasn’t shown to be helpful. 

Following a low-FODMAP diet is difficult as it’s complicated and restricts a large number of foods. It should only be used for 4-6 weeks before foods are re-introduced. 

If you want to try following the low-FODMAP diet, you should discuss it with your healthcare team and get help from a registered dietitian, or else you may miss out on important nutrients. 

Complementary and alternative medicines 
Some people with Crohn’s disease use complementary and alternative medicines (CAMs) to help control their symptoms. However, there are few reliable scientific studies to show the effectiveness of such therapies. Plus, given the unpredictable nature of Crohn’s disease, it’s possible that remission occurred coincidentally.

If you wish to take a complementary or alternative product, talk to your doctor first. Some CAMs, especially herbal medicines, may interact with your prescription drugs.

Probiotics 
There are no clear recommendations regarding the use of probiotics to help induce or maintain remission in people with Crohn’s disease. Speak to your healthcare professional regarding their use. 

Exercise 
When managing Crohn's disease, it’s very important to maintain a healthy lifestyle, even when the disease goes into remission for long periods of time. You can do this by exercising regularly and following a healthy diet. Exercise is also useful to manage your stress levels. 

Reviewed by Kim Hofmann, registered dietitian, BSc Medical (Honours) Nutrition and Dietetics, BSc (Honours) Psychology. December 2017.