Management of difficult inflammatory bowel disease: Where are we now

Abstract

Management of inflammatory bowel disease includes not only drug, endoscopic and surgical therapy but also psychosocial support, dietary and specific nutritional measures: a multidisciplinary medical, surgical, nursing and dietetic approach is essential for all patients, particularly those with complex or refractory disease. In this paper, current treatment of acute severe ulcerative colitis and steroid refractory or -dependent Crohn’s disease is reviewed. Adjunctive intravenous cyclosporin is an alternative to urgent colectomy in steroid-refractory patients with acute severe ulcerative colitis, while the place of intravenous heparin for this indication awaits clarification. Azathioprine or 6-mercaptopurine are useful options in chronically active, steroid-refractory or dependent Crohn’s disease, but may take up to 4 mo to work. Methotrexate is a mo re recent immunomodulatory alternative. Of new therapies selectively aimed at specific pathophysiological targets, the first to reach clinical application is anti-TNF-alpha antibody (infliximab) for refractory Crohn’s disease: its benefits are promising, but experience with it is limited to date, its cost is high and there are uncertainties about long-term safety. In view of the increasing variety and complexity of management options in inflammatory bowel disease, whether apparently responsive or difficult to treat, patients must participate in decisions about which therapies they are to be given.

Key Words: Inflammatory bowel diseases/therapy; Social support; Diet therapy; Crohn’s disease/therapy; Colitis, Ulcerative/therapy; Methotrexate