Crohn's 360: Treating Crohn's, The Stepwise Approach 

Dr. Howard Siegel, Gastroenterologist: Most gastroenterologists are treating their Crohn’s patients in what is called a Stepwise Approach. We want to start with the safest medications with the least side effects and we progress when necessary to more powerful agents with unfortunately more side effects.

We start with usually anti-inflammatory drugs – nonsteroidal anti-inflammatory drugs. The hallmark of therapy being 5 Aminosalicylic acid preparations which come in a variety of sizes and shapes by many different companies. They are very safe medications. They basically coat the intestinal tract with an anti-inflammatory drug.

When that is ineffective we sometimes use antibiotics. For some reason antibiotics seem to decrease the immune response and the inflammation that comes from Crohn’s Disease.

We then will sometimes step up to steroidal anti-inflammatories. Most of us have heard of Prednisone. Prednisone is a steroid that reduces inflammation. We often will use steroids, preferably for a short period of time. We don’t like to put our patients on long-term steroids because of the multiple side effects of being on steroids. 

Although there are multiple side effects of some of our medications, I often  tell my patients that they have to be aware of the side effects of not treating their disease. Every thing we do in medicine, be it Crohn’s Disease or many other illnesses is a risk-benefit ratio. Certainly there are risks of using medications and certainly there are risks of not using medications. I often tell my patients that although you may not want to be on this medication because of the side effects, you really need to think about the side effects of not being on medication. Including untreated inflammation which can lead to: fistulas where the bowel becomes leaky and creates little tracks that can lead to other parts of the body; stricturing or narrowing of  the bowel which can lead to obstructions; bleeding which can lead to hospitalization and anemia. Untreated inflammation increases the incidence of developing into cancer. When Prednisone is needed, and if it is needed for a short period of time, we use it. When it becomes obvious that the patient needs Prednisone for a long period of time we still try to get them off of the Prednisone and then use the Prednisone as a bridge to other agents, such as immunologic agents.

We will often use drugs that are also called “steroid sparing agents.” We use drugs such as Imuran and mercaptopurine which are antimetabolites. These are chemicals that affect the immune system directly and we can use these instead of Prednisone. Many of my patients ask me,  “If they are safer than the steroids’ side effects why don’t you just use them?” And we do. The problem with them is that they take a long time to have an effect. They may take several weeks if not months before they begin to have an effect. When you have a patient in severe pain or with severe diarrhea who is not responding to our non-steroidal anti-inflammatories and perhaps has not responded to antibiotics, sometimes we have to use the steroids to get them into remission or get them under control and give the non-steroidal medications such as the immunologic agents a chance to work.

We also have another class of drugs called the biologic agents. These are medications that have to be given either intravenously or by injection that have an affinity for the inflammatory process itself. They are almost like a guided missile that will seek out the immune reaction where it is occurring and interfere with the immune reaction. These drugs have markedly improved many of our patients who otherwise would have required surgery. Patients say to me, “well what about the risks?” Anytime we interfere with the immune system we are placing the patient at risk of any illnesses that are often treated by a healthy immune system. For example: higher instances of infection, higher instances of certain growths or tumors including lymphoma. There are also risks with being undertreated; and therefore, in many cases, the benefits of the medicine outweigh the risks of the medicine.

When these medications are ineffectual or their effectiveness is short-lived then we have to actually consider surgery to remove the portion of the bowel that is inflamed, that is causing the symptoms, and that is not responding to medical therapy.

This stepwise approach puts surgery often as one of the last lines of defense for Crohn’s Disease.

Be sure to discuss the Stepwise Approach with your doctor to learn about the treatments that work best for your needs.

• Anti-Inflammatory
• Antibiotics
• Steroids
• Antimetabolites
• Biologics
• Surgery