Treatment

General measures

• Avoid NSAIDs (both UC and CD) & tobacco (CD)

• Antidiarrheals only in mild disease; limited role for TPN. but may be needed in severe dz

• Rule out infection before treating with immunosuppressants and biologies

Acute Flare Treatment

Options

5-ASA compounds (oral)

Sulfasalazine (5-ASA • sulfa): bacterial reductases release 5-ASA in colon Mesalamine (5-ASA in pH-sensitive or time-dependent capsules) Asacol: dissolves at pH 6-7 - 5-ASA released in terminal SI & colon Pentasa: 5-ASA released throughout the small intestine & colon Olsalazine & Balsalazide (5-ASA dimer): cleaved in the colon rectal 5-ASA (enemas, suppositories) for distal UC. proctitis Antibiotics metronidazole: useful in perianal, fistulizing. and active colonic CD ciprofloxacin • metronidazole, or clarithromycin useful for active CD Oral steroids: prednisone; budesonide (oral steroid useful in ileocecal CD; low systemic absorption) Intravenous steroids

: infliximab (refractory or fistulizing CD; nejm 1997:337:1029 & 1999:340:1398;

refractory UC; ne/m 2005.353 2462) • cyclosporine for UC <ne;m 1994,3301841)

Serial abd exams • radiographs CT to r o dilatation, perforation, or abscess (tunc« 2007:369 1641)

Maintenance of remission

• 5-ASA compounds (? UC only): appropriate formulation to treat affected areas

• Azathioprine/6-MP: mainstay of maintenance treatment for CD and UC.Thiopurine methyltransferase (TPMT) genotype may be checked before initiation to avoid toxicity.

• Infliximab for CD (ACCENT I.Umcei 2002JS91S41)

• Other: methotrexate for CD (nîjm 2000:342.1627); ? budesonide; adalimumab Indications for surgery

• UC (25% of all Pts): failed medical therapy, hemorrhage, perforation, stricture.

fulminant colitis, toxic megacolon, growth retardation, high-grade dysplasia, or carcinoma

• CD (75% of all Pts): hemorrhage, failed medical therapy. ? chronic steroid requirement, stricture, fistula, abscess, high-grade dysplasia, or carcinoma

Severity

Mild

Moderate Severe

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