The primary goal of treatment in Crohn’s disease is to eliminate symptoms and maintain the general well-being of patients by inducing clinical remission and maintaining it over time (1, 2). Additional goals of treatment include minimizing side effects of medications, modifying the pattern of disease, and avoiding complications (1, 3).
Therapy is sequential and often involves a balance between efficacy and toxicity (4). Conventional therapies such as 5-aminosalicylates are generally used to treat mild to moderate Crohn’s disease (4). Corticosteroids and immunomodulating agents such as azathioprine, 6-MP, and methotrexate are used to treat moderate to sever disease (4). Immunomodulating agents are also used in patients who are either steroid dependant or steroid refractory (4). Antibiotics are used for the treatment of fistulizing disease and other infectious complications of CD (5). Additionally, biologic therapy is uses for moderate to severe disease in patients who have not responded well to conventional therapies (4).
The evolution of research in the underlying pathogenesis of Crohn’s disease has lead to the development of drugs that potentially induce mucosal healing by targeting key pro-inflammatory cytokines (such as TNF-alpha) involved in these processes (3, 4, 6). The central role of TNF-alpha, a key inflammatory mediator involved in mucosal inflammation, has made this mediator a target of several biologic therapies. Biologic response modifiers and immunomodulatory agents that target the underlying inflammatory process in Crohn’s disease have the potential to alter the natural history of the disease (6).
Drug therapy is often not enough to treat patients with severe Crohn’s disease. Hospitalization and surgery (resection, anastomosis) are often needed to manage complications of Crohn’s disease (fistulas, obstruction, strictures, fissures or abscesses) or when medications no longer control symptoms of the disease. Over three-fourths of all Crohn’s disease patients will be hospitalized and will require surgery at least once in their lives (2, 7). One estimate derived from a health insurance claims database stated that 15%-25% of patients require hospitalization in a given year (2). In another prospective study evaluating the natural course of Crohn’s disease, approximately one third of patients with chronically or intermittently active disease developed complications requiring hospitalization and surgery in the first year following diagnosis, 13% in the second year and 3% in each subsequent year (2).
Unlike ulcerative colitis, surgery is not a cure for Crohn’s disease but is performed for disease refractory to medication or for complications. Crohn’s disease historically recurs following surgery. The post-operative recurrence of symptoms or complications requiring surgery in Crohn’s disease is frequent and will vary depending on the pattern and duration of disease prior to initial surgery (7). Re-operation rates in published studies vary from 25%-30% within 5 years and 40%-50% within 20 years (7). The re-operation rate was reported to be as high as 58% in a study of 100 patients with Crohn’s disease (7).
- Hanauer SB, Sandborn W. Management of Crohn's disease in adults. Am J Gastroenterol 2001;96:635-643.
- Lichtenstein GR, Yan S, Bala M, Hanauer S. Remission in patients with Crohn's disease is associated with improvement in employment and quality of life and a decrease in hospitalizations and surgeries. Am J Gastroenterol 2004;99:91-96.
- Travis S. Advances in therapeutic approaches to ulcerative colitis and Crohn's disease. Curr Gastroenterol Rep 2005;7:475-84.
- Panaccione R, Fedorak RN. Primer of current therapies to treat inflammatory bowel disease. In: Satsangi J, Sutherland LR, eds. Inflammatory Bowel Diseases. London: Churchill Livingstone. Elsevier Limited: 2003:335-338.
- Stange EF. Induction of remission in Crohn’s disease. In: Satsangi J, Sutherland LR, eds. Inflammatory Bowel Diseases. London: Churchill Livingstone. Elsevier Limited: 2003:359-372.
- Sninsky CA. Altering the natural history of Crohn's disease? Inflamm Bowel Dis 2001;7 (Suppl 1):S34-9.
- Timmer A. Natural history and prognosis: an evidence-based approach. In Satsangi J, Sutherland LR, eds. Inflammatory Bowel Diseases. London: Churchill Livingstone. Elsevier Limited, 2003:301-317.