Inflammatory Bowel Disease Treatment Guidelines

Diagnosis and Assessment

A stepwise approach to rule out ongoing inflammatory activity should be followed in IBD patients with persistent GI symptoms using fecal calprotectin measurement, endoscopy with biopsy, and cross-sectional imaging 2, 3
Anatomic abnormalities or structural complications should be considered in patients with obstructive symptoms including abdominal distention, pain, nausea, vomiting, or constipation 2, 4
Alternative pathophysiologic mechanisms should be evaluated based on symptom patterns, including small intestinal bacterial overgrowth, bile acid diarrhea, and carbohydrate intolerance 3, 4

Aminosalicylates (5-ASA compounds) are effective for mild to moderate ulcerative colitis for both inducing and maintaining remission, but have less effectiveness in Crohn's disease 1

Immunomodulators (azathioprine, mercaptopurine) are recommended for chronic active steroid-dependent disease, with regular monitoring of full blood count to detect neutropenia 1, 5

For diarrhea control in Crohn's disease, hypomotility agents or bile-acid sequestrants may be used for chronic diarrhea in quiescent IBD 3, 1
Osmotic and stimulant laxatives should be offered to IBD patients with chronic constipation 2, 6
Antispasmodics, neuropathic-directed agents, and anti-depressants should be used for functional pain in IBD, while opiates should be avoided 3, 1
For IBD-associated arthropathy related to IBD activity, the mainstay of symptom relief should be through control of intestinal inflammation, physiotherapy, and simple analgesia 5

A low FODMAP diet may be offered for management of functional GI symptoms in IBD with careful attention to nutritional adequacy 2, 1
Psychological therapies including cognitive behavioral therapy, hypnotherapy, and mindfulness therapy should be considered for IBD patients with functional symptoms 3, 7
Probiotics may be considered for treatment of functional symptoms in IBD 4, 1
Physical exercise should be encouraged in IBD patients with functional GI symptoms 7, 1
Solution-focused therapy for fatigue in quiescent IBD has shown reduction in fatigue for up to 3 months following completion of therapy 5

Surgery is recommended for ulcerative colitis not responding to intensive medical therapy, with decisions best made jointly by gastroenterologist and colorectal surgeon in consultation with the patient 1
For Crohn's disease, surgery should only be considered when symptomatic, as it is potentially panenteric and usually recurs following surgery 1

IBD patients should be asked about symptoms of fatigue, as it is common and often not reported, and does not necessarily correlate with disease activity 5
Patients experiencing fatigue should be investigated for subclinical disease activity and other potentially modifiable factors such as sleep pattern, medication side effects, anemia, iron deficiency, and vitamin deficiencies 5
Type 1 peripheral arthropathy (affecting less than five joints) is usually associated with flares of IBD and responds well to treatment of the underlying disease 5
Type 2 arthropathy (more than five joints) is usually independent of gut inflammation and may require referral to a rheumatologist for consideration of immunomodulator or biological therapy 5

Regular self-assessment of the IBD unit should be conducted to see how quality of care and service may be improved 8