Getting current on the treatment of inflammatory bowel disease

Inflammatory bowel disease (IBD) is the most common chronic gastrointestinal (GI) disease of childhood and adolescence, and is characterized by chronic inflammation of the GI tract and by inflammation-related intestinal and extraintestinal complications. For purposes of treatment, two types of IBD are recognized: Crohn's disease and ulcerative colitis (UC). In Crohn's disease, soreness, inflammation, and swelling of the wall of the small or large intestine causes abdominal pain, diarrhea, fever, and weight loss. In UC, inflammation and ulceration of the inner lining of the colon causes abdominal pain, diarrhea that may be mixed with blood, and, occasionally, joint pain. Genetic, microbial, environmental, and immunologic variables have been implicated in the etiology of IBD, which makes treating the disease a challenge in adults and children.

Treatment for IBD has traditionally been directed at controlling inflammation with the use of 5-aminosalicylates, corticosteroids, and immunomodulators. As researchers continue to identify mechanisms that cause inflammation, however, other treatments, including nutritional therapy, probiotics, antibiotics, and biologics, are also being used. The efficacy of traditional treatments also has been enhanced, as additional corticosteroids have become available, along with new information about how immunomodulators work. Table 1 summarizes medications used to treat IBD in children.

We focus this discussion on the latest therapies (primarily for Crohn's disease), the rationale for their use, and their potential for complications.

What is new in treatments for IBD?

Nutritional intervention has become an important treatment modality for children with IBD.^3-8 In addition, therapeutic manipulation of enteric microflora-using primarily antibiotics and probiotics-to improve the balance of aggressive and protective bacterial species in the patient with IBD has been used. Last, biologic agents targeted against proinflammatory cytokines have shown promise as a therapy for IBD.

Nutritional therapy. Growth delay or failure is a major concern in a child with IBD, and longitudinal growth is inversely related to disease activity. Multiple mechanisms responsible for growth failure in this disease include suboptimal caloric intake, intestinal inflammation that results in malabsorption of nutrients, the presence of inflammatory mediators that suppress growth, and side effects of drugs, such as corticosteroids, used to treat IBD.^4-6 Control of disease activity allows for normal growth and pubertal development.^3-5 Regardless of the direct effect that nutrition may have on inflammation, optimizing nutrition in the child with IBD is an important goal.

Although interest in enteral nutrition as a primary therapy for Crohn's disease is not new, its role is poorly defined. Recent studies have helped clarify this issue, however: Whereas corticosteroid therapy appears to be superior to enteral nutrition in inducing remission in adults with Crohn's disease, a recent meta-analysis showed that, in children, corticosteroids and enteral nutrition had comparable efficacy.⁹