Internal Medicine

Therapy of Crohn's disease

Crohn's disease therapy

The goal of Crohn's disease therapy is to lessen the relapses and relieve symptoms. The therapy of the relapses is based on the severity. A cure for Crohn's disease does not exist to this day. If the therapy setting is optimal, the Life expectancy with Crohn's disease, however, hardly or not at all restricted.

Read more about these topics: Medicines for Crohn's disease and Life expectancy in Crohn's disease

The relapses are after CDAI (C.rohns D.isease A.ctivity I.ndex) (the last number indicates the respective weighting factor):

Number of soft stools in the past week x2
degree of stomach pain x5
General condition for 1 week x7
Other Crohn's Disease Associated Symptoms x20
Symptomatic Diarrhea treatment in the last week x20
Palpable resistance / resistance in the abdomen x10
Hematocrit (Proportion of red blood cells to proportion of fluid in the blood) x6
Weight (1- (weight / standard weight)) x10

From one CDAI> 150 is it about one thrustthat should be treated.
The Therapy of the acute episode (CDAI> 150) where only the Small intestine is affected consists in the administration of steroids (e.g. Prednisolone).
As undesirable effects, in addition to the desired immunosuppression, occur u. a. Diabetes mellitus and increased levels of glucose in the blood.

If colon involvement occurs during an acute flare-up, steroids will be plus Salazosulfapyridine (SASP) or 5- aminosalicylic acid (5- ASA: mesalazine) given. SASP and 5-ASA have an inhibitory effect on inflammatory processes.

Read more on the topic: Crohn's disease attack

Fistulas that appear in Crohn's disease are treated with medication by administering antibiotics (metronidazole). Administration is contraindicated in the first trimester of pregnancy and while breastfeeding.
If this therapy fails, the problem must be tackled surgically. Rashes, nausea and vomiting can occur as side effects.

Diarrhea is usually treated with loperamide, taking care to avoid constipation (Constipation) arises.
The active ingredient loperamide inhibits bowel movements (peristalsis), stool frequency and increases uptake (Absorption) of water and electrolytes.

Read more on the topic: Loperamide

Vitamins, trace elements and fluids are also given so that there are no deficiency situations.

If surgical therapy remains the only form of therapy for Crohn's disease, there is usually an obstruction of the intestine (Ileus) that hinders the passage of the chair. If there is a perforation, i.e. a rupture of the intestinal wall, or an accumulation of pus within the abdominal cavity, an operation is also urgently required. The strategy of surgical therapy is to preserve as much of the intestine as possible, i.e. to remove as little intestine as possible.

In the case of malnutrition and a reduced general condition, tube feeding should be considered.

Therapy of the acute episode

Crohn's disease is a chronic inflammatory disease that occurs in bursts. Symptom-free phases alternate with acute flare-ups. In the acute episode, the disease is active and sections of the gastrointestinal tract are inflamed. An acute attack should always be accompanied by a doctor in order to contain the inflammation as quickly as possible.

Read more on this topic: inflammatory bowel disease

Therapy takes place on several levels. In addition to drug therapy, diet must also be adjusted. The aim of drug therapy is to relieve symptoms such as pain and cramps and also to contain inflammation.

In the event of a weak episode, mesalazine may be sufficient. The drug acts locally in the intestine and inhibits inflammation there.

If the thrust is more pronounced, it is enough Mesalazine not off and the administration of cortisone is necessary. There are different forms of administration of cortisone. First of all, cortisone is only given locally (Budesonid® tablets) so that the active ingredient works directly on the intestinal mucosa. This is achieved, for example, with specially coated tablets that are swallowed and only dissolve from the small intestine. Enemas containing cortisone and foam preparations (Budensonid® foam) that are introduced from the rectum only have a local effect and mainly reach the large intestine. If the local administration of cortisone is insufficient, cortisone must be administered systemically (prednisolone), i.e. via the bloodstream, and thus reaches the entire body in addition to the intestine. Systemic cortisone therapy is sufficient in most cases.

As a final step, the therapy can be supplemented with immunosuppressants, i.e. drugs that suppress the immune system. Examples of immunosuppressants are: Humira®, azathioprine and methotrexate (MTX).

When it comes to nutrition, it is very important to have sufficient water intake, as the body loses a lot of water during an acute episode due to diarrhea. A good intake of calories is also important, as the body needs the energy to regenerate. This should be taken from easily digestible foods so as not to put additional strain on the gastrointestinal tract. Examples are white bread and pureed vegetable soups.

You might also be interested in: Causes of Crohn's Disease

Medication

Various groups of drugs are used in Crohn's therapy and prophylaxis (Please also read: Drugs for Crohn's disease). An important group are the glucocorticoids, which are also known as cortisone preparations. A distinction is made between systemic and topical, i.e. only locally effective, cortisone preparations.

Read more on this topic: Glucocorticoids

There is also the group of salicylates. The active ingredients Sulfasalazine and Mesalazine are, for example, contained in drugs with the trade names Sulfasalazin HEXAL®, Pentasa® or Asacolitin®.

The immunosuppressive drug group includes the Cytostatics Azathioprine and methotrexate and the man-made antibodies such as Infliximab or Adalimumab, which are also called Biologicals will be referred to.

Read more on this topic: Immunosuppressants, Infliximab

Read more on the topic: Can Crohn's Disease be curable?

Cortisone

Therapy with Cortisone is an integral part of Crohn's disease treatment. In addition to cortisone, one often speaks of in medicine Steroids or Glucocorticoids / Corticoids. All names refer to the active ingredient cortisone.

Cortisone is not just a drug, it's a too Messenger substance (hormone)that the body produces itself in the adrenal gland. Cortisone can be produced artificially and used as a drug. Cortisone is the body's own hormone and drug at the same time. When used as a drug, the dosage used is significantly higher than that normally found in the body.

Cortisone has many effects. The main effect is the suppression of the immune system. This is useful in an acute episode of Crohn's disease, as the drug works by blocking the immune system to reduce inflammation. Cortisone also affects the metabolism, bones and muscles.

Cortisone is also known as a stress hormone because it activates energy reserves in stressful situations and increases blood sugar levels.

Examples of cortisone preparations are the active ingredients prednisolone (Prednison®, Decortin® H) and budesonide (Budenofalk®, Entocort®).

What is important to know is that Cortisone must always be tapered off. This means that cortisone must not be stopped suddenly, but that ever smaller amounts of cortisone are taken every day. This is the only way the body has time to ramp up its own cortisone production.

Humira

Humira® is the trade name of the drug with the active ingredient adalimumab and is one of the so-called Biologicals. Adalimumab is an artificially produced antibody that intervenes very specifically in the immune system. Antibodies are also found in the healthy immune system. They are small Y-shaped bodies that are produced by immune cells and are used to mark pathogens. The antibody inhibits the inflammatory messenger TNF-alpha (Tumor necrosis factor-alpha), which is increasingly formed in the intestinal wall in Crohn's disease. The messenger substance is, so to speak, intercepted by Humira® and can no longer heat up the immune system. The inflammatory response in Crohn's disease is dampened and the intestine can recover.

Humira® must be stored in a cool place and injected under the skin, e.g. on the stomach. At the start of therapy, a higher dose is required in the first 2 weeks, after which it is sufficient to inject every 14 days. Possible side effects are acute allergic reactions, irritation of the injection site, skin changes, nausea, vomiting and headache. Unfortunately, Humira® does not only intervene in the intestines, where the effect is desired, but also in the immune system of the entire body. Humira® can, for example, weaken the immune system's defense against pathogens, which, for example, leads to an increased susceptibility to colds. The defense against the body's own cancer cells can also be weakened. According to the current state of research, an increased cancer risk from Humira® cannot be ruled out.

Injection therapy

Injections may be necessary in Crohn's disease in the following situations:
Crohn's patients develop one Vitamin B12 deficiency-related anemia, vitamin B12 needs to be replaced. The best way to do this is to inject it into the fatty tissue just under the skin (subcutaneous Injection), by injection into a muscle (intramuscular Injection) or directly by injection into the bloodstream (intravenous Syringes). This bypasses the intestine through which vitamin B12 is normally absorbed.

As part of the therapy of an episode different things come about Medication are used, which are also given as a syringe. These include: MTX, which is injected under the skin every week, the artificially produced antibodies Adalimumab (Humira®), Infliximab (Remicade®) and Ustekinumab (Stelara®), which can be given by the patient as injections under the skin or by the doctor as an infusion.

Infusion therapy

Infusion is the term given to the administration of large amounts of fluid into the body. The liquid is given directly into the bloodstream. To do this, an indwelling venous cannula, i.e. access to a peripheral vein, e.g. be placed in the crook of the arm or on the forearm. The infusion bag with the liquid is connected to this access via a plastic tube. Infusion through a central vein, e.g. on the neck is possible.

The infusion can be pure hydration or the gift of certain Electrolytes, Nutrients or drugs serve. Drugs that can be given as an infusion as part of Crohn's therapy are the following:

1. antibody how Adalimumab, Infliximab and Vedolizumab. These active ingredients are contained in the drugs called Humira®, Remicade® and Entyvio®.

2. Immunosuppressants how Methotrexate. The active substance Methotrexate is contained, for example, in drugs with the names MTX®, Lanatrel® and Metex®.

nutrition

There are no specific dietary guidelines for Crohn's disease. However, an individually tailored diet can significantly improve wellbeing.

It is important to know that food is tolerated differently during symptom-free times than during an acute episode. In the acute episode, when the intestinal mucosa is inflamed and permanent diarrhea occurs, dietary fiber and too much fat should be avoided. Dietary fiber is a vegetable component of food that cannot be digested in the small intestine. Fruits, vegetables, whole grain products and legumes such as beans, peas or lentils are high in fiber. In addition, strong stimuli such as fatty, spicy, sweet, sour, very hot or very cold should be avoided.

Since the body loses a lot of water through diarrhea, it is important to drink enough water. Still water and herbal teas are best suited for this. Sweet juices, carbonic acid, coffee, black tea and alcohol are unfavorable. High-calorie drinking food can also be used if the energy and nutrient supply is insufficient through the restricted food intake in the push. Another option is to eat through an access in the blood vessel to relieve the intestines. This is known as parenteral nutrition.

In the remission phase, i.e. the recovery phase after an episode of illness, fiber is recommended. For example: finely ground whole grain products, fruit and vegetables in pureed form, boiled or steamed vegetables, oatmeal and rice. Most of those affected tolerate more poorly: bananas, sweets, yeast pastries, wheat, corn and eggs. Overall, the diet should not be too one-sided out of fear of intolerance. If deficiencies arise due to poor absorption of nutrients by the damaged intestine, these substances must be replaced. These include, for example, certain vitamins, zinc, calcium or protein. Such a deficiency can also exist if a person is visually well nourished. A check by a doctor is therefore important.

In addition, a diagnosis of intolerance and allergies is recommended so as not to put additional strain on the intestines. Approx. For example, 30% of Crohn's patients suffer from lactose intolerance. This means that they lack an enzyme that breaks down lactose. These people should resort to lactose-free dairy products.

In addition to nutrition, nicotine plays an extremely important role. Studies show that not smoking has a positive effect on the course of the disease. There are fewer relapses and the medication can work better. Sports, exercise and dealing well with stress can also have positive effects.

surgery

With Crohn's disease always will first tried purely conservative, so purely medicinal to treat. But there are situations in which a surgery urge in Crohn's disease necessary is. These include the following 3 situations: a Obstruction of the bowel, one Abscess formation (an abscess is an encapsulated inflammation, i.e. a cavity filled with pus) and the perforation, a breakthrough in the intestine. In the case of a perforation, intestinal contents can enter the abdominal cavity, which is very dangerous as this leads to life-threatening inflammation (Acute abdomen) can lead. These complications of the disease can be averted with surgery.

A Cure the disease in itself is also With one Operation not possible. Another complication that is occasionally operated on is that fistula. However, people are very cautious about the decision to have surgery, as the chances of success are often not so good. The Healing after surgery is in Crohn's disease patients very tedious and often brings complications.

Therapy of a fistula

Fistulas are a common complication in Crohn's disease. A fistula is one corridor connection, the not natural, but as part of the disease arises. A distinction is made between inner fistulas, which connect intestinal sections with each other or blindly, and outer fistulas, which connect the rectum to the skin surface. They often mean a high level of suffering. Fistulas also occur in people without Crohn's disease.

If Crohn's disease is the cause of the fistula, the therapy differs, however. Fistulas that do not cause problems should not be operated on, because wound healing is often disturbed in Crohn's disease patients. Fistulas that cause pain or secretion can be caused by a thread for draining wound and body fluids (drainage) or by a Fistula splitting (Fistulotomy), be treated. In the Fistulotomy the fistula duct is opened lengthways and a wound surface is created that has to heal openly. Fistulas that affect the sphincter muscle must not be split, otherwise there is a risk of fecal incontinence. Antibiotics are also used for severely inflamed fistulas with a fever. It is also hoped that some of the anti-inflammatory drugs will have a positive effect on fistulas.

Naturopathy / homeopathy

Naturopathy is part of complementary medicine, so it is not a stand-alone alternative, but a good complement to conventional medicine. Preparations that are taken in addition, even if they are purely herbal and freely available, must always be discussed with the attending physician, as interactions with the prescribed medication are possible. Herbal supplements used by Crohn's patients include: frankincense, myrrh, flea seeds, wormwood and chamomile flowers.

Unfortunately, the available studies on the individual plant substances are not sufficient. Often only very few patients (sample size <10) were considered.

At this point you can also read the main page on the promising medicinal plant soft smoke: What is the use of soft smoke?

Traditional Chinese medicine

The Traditional Chinese medicine (TCM) is part of complementary medicine, so it is in addition to conventional standard therapy used. Behind the collective term TCM there are various methods for diagnosing and treating diseases. The basic idea is that an imbalance of forces is the cause of illness.

The methods used include Massage techniques, Heat treatments, acupuncture and forms of meditation and movement such as Chigong. These methods can also provide relief from Crohn's disease. However, as with almost all alternative and complementary medical procedures, the costs for this are not covered because the methods are not scientifically proven.