Your treatment plan
If you are diagnosed with Crohn's disease, your care team will draw up a treatment plan for you. There are three goals in your treatment plan:
- treat the active disease, in order to resolve your symptoms
- prevent your symptoms returning with maintenance therapy
- treat any returning symptoms with relapse therapy
Steroids are a type of hormone medication. Hormones are groups of powerful chemicals that have a wide range of effects on the body. One such effect is to reduce inflammation.
Steroids are usually only used to treat the active disease because their long-term use is associated with a range of adverse side effects.
Budesonide and prednisolone are two steroids that are often used to treat Crohn's disease.
Budesonide is usually the first steroid that is prescribed to help control the symptoms of Crohn's disease.
If you take budesonide on a short-term basis (fewer than 12 weeks) you may experience the following side effects:
- swelling of the face
- swelling of the hands, arms, feet and legs due to a build-up of fluids (oedema)
- mood changes, such as feeling irritable or anxious
If you take budesonide for more than 12 weeks, you may experience the following side effects:
- thinning of the bones (osteoporosis)
- increased vulnerability to infection
- cataracts (a type of eye condition)
- muscle cramps and stiffness
If you need to take budesonide for more than 12 weeks, you may be given vitamin D and calcium supplements to help protect against the effects of osteoporosis. Both of these supplements help to strengthen the bone.
Due to your increased vulnerability to infections, you should avoid close contact with people who are known to have infections, particularly those with chickenpox, measles and shingles.
You should not suddenly stop taking budesonide because doing so can cause adverse effects. When you no longer need to take your medication, your dose will be gradually reduced over time.
Prednisolone is used in cases where budesonide proves ineffective, or where your symptoms are moderate to severe.
Prednisolone has the same type of short-term and long-term side effects as budesonide. In addition, prednisolone has been known to cause mental health problems in an estimated 5% of people.
- feeling depressed and thinking about suicide
- feeling very excited and happy
- experiencing sudden and severe mood changes (happy one minute, very depressed the next)
- feeling anxious
- having problems thinking clearly and feeling particularly confused
- memory loss
- hallucinations (seeing and hearing things that are not real)
If you experience any of these symptoms, contact your GP as soon as possible because your dose may need to be adjusted.
The advice outlined above about avoiding people with infections and not suddenly stopping your prescribed dose also applies to prednisolone.
Sulfasalazine belongs to a group of medicines called aminosalicylates. Aminosalicylates are known to reduce inflammation inside the colon.
Sulfasalazine can be used as an alternative to steroids to treat mild cases of Crohn's disease.
Depending on exactly where the inflammation is occurring, you may be given sulfasalazine in tablet form or as a suppository. A suppository is a capsule that you insert into your anus (back passage).
Common side effects of sulfasalazine include:
- abdominal pain
If side effects become particularly troublesome, you should tell your GP as the dose used may need to be adjusted.
Immunosuppressants are a type of medication to suppress the activities of the immune system in order to help reduce inflammation on a long-term basis.
Immunosuppressants are used in maintenance therapy and in combination with steroids when a person has a relapse of symptoms.
Two immunosuppressants that are widely used for treating Crohn's disease are azathioprine and mercaptopurine.
Depending on the severity of your symptoms, you may be given azathioprine in tablet form or as an injection.
Common side effects of azathioprine include:
- increased vulnerability to infection
- bleeding and bruising more easily
Due to your increased vulnerability to infection, you should avoid people with a known chickenpox or shingles infection.
Less common side effects of azathioprine include:
- shortness of breath and dizziness when exercising
Mercaptopurine was originally developed to treat leukaemia (cancer of the blood cells), but it has since proved effective in the treatment of Crohn's disease.
As mercaptopurine is given in tablet form, its side effects are not as severe as those associated with other forms of chemotherapy treatment.
Common side effects of mercaptopurine include:
Less common side effects of mercaptopurine include:
- loss of appetite
- feeling tired, breathless and weak, which is caused by a drop in the number of red blood cells (anaemia)
Mercaptopurine can also temporarily affect the quality of a woman's eggs and a man's sperm, which could increase the risk of birth defects. It is therefore very important to use effective contraception if you are sexually active and you are taking mercaptopurine.
Biological therapies are a new type of medication. They are created using naturally occurring biological substances, such as antibodies and enzymes.
There are currently two biological therapies licensed for use in England:
Each medication is discussed in more depth below.
Infliximab is usually only recommended in severe cases of Crohn's disease that have not responded to steroid and immunosuppressant treatments, and where the person is unsuitable for surgery.
For example, if a person has had previous surgery to remove a section of bowel, removing more of the bowel could result in a loss of digestive function. Alternatively, a person may be in too poor a state of health to withstand the effects of surgery.
Infliximab works by targeting the tumour necrosis factor (TNF) antibodies that are responsible for much of the inflammation that is associated with Crohn's disease.
Infliximab is given through a drip in your arm over the course of two hours. This is known as an infusion.
Depending on how well your symptoms respond to treatment, you may only require one infusion, or you may have three infusions that are given every eight weeks.
Around one person in four has an allergic reaction to infliximab and experiences symptoms such as:
- joint and muscle pain
- itchy skin
- high temperature
- swelling of the hands and/or lips
- problems swallowing
Symptoms can range from mild to severe and they usually develop in the first two hours after the infusion has finished.
However, in a minority of cases, people have experienced a delayed allergic reaction days, or even weeks, after an infusion. If you begin to experience the symptoms listed above after having infliximab, you should seek immediate medical assistance.
Due to the significant risk of having a severe allergic reaction (one in four), your health will be carefully monitored after your first infusion and, if necessary, powerful anti-allergy medication, such as intravenous steroids, may be used.
There have been several cases where infliximab has reactivated a previously dormant tuberculosis (TB) infection. Therefore, it may not be suitable for you if you have a previous history of TB. Infliximab is also not recommended for people with a history of heart disease.
Infliximab will also make you more vulnerable to infection so you should avoid contact with people who have a known chickenpox or shingles infection.
You should report any symptoms of a possible infection, such as coughs, a high temperature or a sore throat, to your GP.
Another biological therapy available for people with severe Crohn's disease is a medication called adalimumab. Adalimumab works in a similar way to infliximab by targeting TNF antibodies.
Adalimumab is given by injection and most people will need to have an injection every two weeks. Your GP or practice nurse will be able to teach you how to administer the injections yourself at home.
Like infliximab, adalimumab will make you more vulnerable to infection, so if you are taking it you should avoid contact with people with chickenpox or shingles and always report any symptoms of a possible infection to your GP.
Adalimumab can cause reactivation of the hepatitis B virus in people who were previously infected. If you know you have previously been infected with hepatitis B, you should inform your GP because adalimumab may not be suitable for you.
Common side effects of adalimumab include:
- pain, swelling, redness and itching at the site of the injection
- abdominal (tummy) pain
- nausea (feeling sick)
- vomiting (being sick)
- skin rash
- muscle, joint and bone pain
- respiratory tract infections, such as colds, a runny nose and pneumonia (lung infection)
Surgery is often required when the symptoms of Crohn's disease cannot be controlled using medication alone. An estimated 80% of people with Crohn's disease will require surgery at some point in their life.
Surgery cannot cure Crohn's disease, but it can provide long periods of remission, often lasting several years. During surgery, the inflamed section of the digestive system is removed and the remaining part is reattached.