Pharmacological- and non-pharmacological therapeutic approaches in inflammatory bowel disease in adults

Abstract

Inflammatory bowel diseases (IBDs) are a group of chronic inflammatory conditions mainly of the colon and small intestine. Crohn’s disease (CD) and ulcerative colitis (UC) are the most frequent types of IBD. IBD is a complex disease which arises as a result of the interaction of environmental, genetic and immunological factors. It is increasingly thought that alterations of immunological reactions of the patients to their own enterable bacteria (microfilm) may contribute to inflammation. It is characterized by mucosal and sub mucosal inflammation, perpetuated by infiltration of activated leukocytes. CD may affect the whole gastrointestinal tract while UC only attacks the large intestine. The therapeutic goal is to achieve a steroid-free long lasting remission in both entities. UC has the possibility to be cured by a total colectomy, while CD never can be cured by any operation. A lifelong intake of drugs is mostly necessary and essential. Medical treatment of IBD has to be individualized to each patient and usually starts with anti-inflammatory drugs. The choice what kind of drugs and what route administered (oral, rectal, intravenous) depends on factors including the type, the localization, and severity of the patient’s disease. IBD may require immune-suppression to control symptoms such as prednisolone, thiopurines, calcineurin or sometimes folic acid inhibitors or biologics like TNF-α inhibitors or anti-integrin antibodies. For both types of disease (CD, UC) the same drugs are available but they differ in their preference in efficacy between CD and UC as 5-aminosalicylic acid for UC or budesonide for ileocecal CD. As therapeutic alternative the main mediators of the disease, namely the activated pro-inflammatory cytokine producing leukocytes can be selectively removed via two apheresis systems (Adacolumn and Cellsorba) in steroid-refractory or dependent cases. Extracorporeal photopheresis results in an increase of regulatory B cells, regulatory CD8⁺ T cells and T-regs Type 1. Both types of apheresis were able to induce clinical remission and mucosal healing accompanied by tapering of steroids.

Keywords: Inflammatory bowel disease; Crohn’s disease; Ulcerative colitis; Extracorporeal treatment; Step up/top down; Psychological aspects in inflammatory bowel disease; Current medical treatment of inflammatory bowel disease; Future therapeutical strategies

Core tip: This review describes current and future therapeutic strategies in Crohn’s disease and ulcerative colitis and outlines the most important publications in this field. It comprises surgical, medical and extracorporeal treatment options. All described treatment options are carefully reviewed regarding therapeutic effects and side effects. Extracorporeal treatment options are a potent measure to withdraw patients from steroids. Standard treatment as well as innovative therapeutic approaches, like autologous stem cell transplantation are addressed, which revealed promising results in therapy refractory patients.