Medical management of inflammatory bowel disease

The medical management of patients with inflammatory bowel disease derives from attempts and errors. Historical studies have shown the utility of corticosteroids for inducing remission of attacks of ulcerative colitis and for active Crohn's disease; sulfasalazine has been mainly used for preventing relapses in ulcerative colitis patients. Immunosuppressive agents such as azathioprine or 6-mercaptopurine have been used either in steroid-resistant patients or those with refractory disease, and now cyclosporine is under clinical investigation. Antibiotics, above all metronidazole, have shown efficacy in patients with Crohn's disease, mainly with perianal involvement, and now tobramycin seems to have a role in active colitis. The oral aminosalicylate derivatives, a second generation of sulfasalazine, have been shown to be effective in preventing relapses in ulcerative colitis and Crohn's disease patients. When administered at high dosages, they have also controlled mild attacks of active ulcerative colitis and of Crohn's disease as well. Their primary indication, however, is for patients who cannot take sulfasalazine. Topical administration of mesalamine has been used with excellent results. This agent is given either in enema or suppository form in patients with distal colitis. Nutritional support seems to have a role as a primary therapeutic step in active Crohn's disease and also as long-term treatment. A new exciting area of investigation is the possibility of selective inhibition at different levels of the inflammatory cascade.