MEDICAL-TREATMENT OF INFLAMMATORY BOWEL-DISEASE

Medical treatment of ulcerative colitis and Crohn's disease is based on the results of clinical trials. For treatment of ulcerative colitis, in addition to the use of corticosteroids at different dosages and routes according to severity of attacks, there is now a place for high dosage of oral mesalamines or, even better, for topical treatment using suppositories or rectal enemas; the use of mesalamine colonic foams seems promising. Enemas with corticosteroids, which are topically active and have no systemic effects, are providing good results. Long-term treatment has been done with sulfasalazine; now new oral mesalamine or diazoderivative compounds are available and rectal mesalamine preparations have shown a prophylactic effect. Treatment of pouchitis, usually with metronidazole, might benefit also by a topical approach-either with mesalamine or steroids. Crohn's disease patients might be more safely treated using new corticosteroids along with traditional steroids, which can avoid systemic side effects, but high dosages of oral mesalamines are also useful to induce remission. The antibacterial agent metronidazole appears to be beneficial, whereas the role of antimycobacterial agents needs further clinical investigation. For prevention of relapse, low or intermittent dosage of steroids seems to offer some benefit and possibly oral mesalamine. In refractory or steroid-dependent Crohn's disease, patients on azathioprine or 6-mercaptopurine usually have a better outcome, whereas cyclosporine is effective in a short, but not long-term, period. Methotrexate should be cautiously used in patients in whom immunosuppressive agents have failed. New selectively acting agents, such as lipoxygenase inhibitors, eicosapentanoic acid, free-radical scavengers, and interleukin-1 receptor antagonists, are now under clinical investigation.