Abdullah Assiri, PharmD

An Effective Treatment Plan Is Crucial for Patients with Crohn’s Disease and Ulcerative Colitis.

Inflammatory bowel disease (IBD) is an idiopathic disease that comprises 2 major disorders: ulcerative colitis (UC) and Crohn’s disease (CD).

 IBD epidemiology has been evaluated by several studies in several geographic areas. The incidence and prevalence of both disorders are higher in North America than other areas such as Asia and the Middle East.

 The incidence and prevalence rate for UC was about 2.2 to 14.3 cases per 100,000 person-years, and 37 to 246 cases per 100,000 persons, respectively, and about 3.1 to 14.6 cases per 100,000 person-years, and 26 to 199 cases per 100,000 persons for CD.

 It is thought to be a result of abnormal luminal flora activity that leads to inappropriate mucosal immune system activation, genetic predisposition that significantly contributes to the development of the disease, or environmental or antigenic factors.

Crohn’s disease generally affects any region of the gastrointestinal tract from the mouth to the anus, though it is more often involved in the small intestine.

 CD usually presents itself through fever, abdominal pain, weight loss, and bloody or non-bloody diarrhea. Around half of CD patients are diagnosed with extraintestinal manifestations such as arthritis, uveitis, and erythema. In CD, many proinflammatory cytokines are released in response to immune system dysregulation. These cytokines play an important role in the development of the disease.

 Most of the identifiable cytokines are derived from type-1 T-helper cells that include interferona and TNF-a IL-1, IL-6, and IL-12. These cytokines activate macrophages and increase the matrix metalloproteinase production in mucosal cells. The distribution of disease with CD is different than that of UC as the most affected area is the terminal ileum and colon; around 20% of patients have isolated colonic involvement. It is uncommon to see CD patients without small or large intestinal disease involvement.

The patient’s medical history and clinical examinations (including endoscopic, radiologic, serological, and histologic findings) are crucial to the diagnosis of CD.

 CD and UC are very similar in their symptoms, thus 10% to 15% of patients with IBD cannot be further diagnosed with CD or UC. However, it is very important for clinicians to diagnose the patient correctly with either CD or UC so that the right treatment plan can be chosen.

Ulcerative colitis is another form of inflammatory bowel disease.

 Ulcerative colitis affects the intestinal mucosa, where inflammation starts in the rectum and can extend to the proximal colon and could possibly affect the entire large intestine. One important difference between CD and UC is that the rectum is always involved in UC. It is not enough to diagnose the patient with UC without defining the extent and severity of inflammation. Determining the severity of the disease helps the clinician select the appropriate treatment plan and allows for a more accurate prognosis.

		Hypercoagulability resulting in venous thromboembolism

		Suppress the inflammation during acute illness and induce remission

		Maintain remission and prevent complications

		Prevent treatment-associated adverse effects

		Minimize surgical intervention and hospitalization

The management of IBD has been focused on the relief of signs and symptoms while optimizing therapy until the desired response is achieved.

 This approach is called the conventional approach; therapy is intensified as the disease worsens. It is focused on inducing remission of the disease, followed by withdrawal therapy once a cure is achieved (Table 1). With the advent of biological treatments, the medical approach has been shifted from symptomatic care to mucosal healings. However, clinicians are still hesitant to start therapy with these agents due to their significant cost and safety profiles. Table 2 summarizes the medical approach for both CD and UC.

Aminosalicylate derivatives are commonly used for inducing and maintaining remission of inflammatory bowel disease.

 They are most effective in treating mild to moderate UC while their efficacy in CD is still not proven. They are available in different several formulations (eg, Azulfidine, Asacol, Delzicol, Asacol HD, Pentasa, Dipentum, Colazal, Apriso, Lialda) that target various gastrointestinal tract areas (Online Table 3). The side effect profile for aminosalicylates varies between the agents. Common drug-related adverse effects include nausea, vomiting, dyspepsia, and fatigue.

Aminosalicylates for Inflammatory Bowel Disease Management

				Abdominal pain, loss of appetite, nausea, vomiting, oligozoospermia

				Stool frequency, complete blood count, urinalysis, and renal function test

				Abdominal pain, diarrhea, nausea, vomiting

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An Effective Treatment Plan Is Crucial for Patients with Crohn's Disease and Ulcerative Colitis.