The aims of both medical and surgical treatment are to help give the patient the best possible quality of life by reducing symptoms and trying to induce and maintain patients in remission. If inflammation is chronic and left untreated, it will ultimately lead to poorer outcomes for the patient.  

Corticosteroids

There is evidence of increased mortality in IBD patients on long-term steroids, so it is important to try to keep patients in remission and prevent the need for multiple steroid courses. If IBD patients require more than two steroid courses over a period of 12 months, it shows their normal maintenance treatment is not effective and needs to be stepped up. 

Calcium and vitamin D supplements are required when repeated steroid courses are prescribed, particularly when using steroids for flare ups. A proton-pump inhibitor (PPI) such as omeprazole may also be prescribed to help reduce adverse effects of steroids such as GI bleeding or dyspepsia.

Aminosalicylates 

It is thought that aminosalicylates have a protective effect in reducing the risk of IBD-associated colorectal cancers, although there is a lack of long-term efficacy studies for this. Patients may prefer to take the full dose once a day or split it into two or three divided doses throughout the day. Once-a-day dosing may help with compliance.

Due to the risk of serious side effects, full-blood count, liver function tests and creatinine should be monitored as per the BNF recommendations for all brands of aminosalicylates.

Immunosuppressants/immunomodulators

The thiopurines azathioprine and mercaptopurine should be started at the full dose. There is no evidence that starting at low doses and then gradually increasing up to target improves safety or tolerance. Low-dose initiation may cause significant delay in achieving the correct target dose as thiopurines may take 12 to 16 weeks to start having a clinical effect. The medication should be taken with meals and with at least a 200ml glass of liquid. During treatment, metabolite levels should be checked to ensure compliance and appropriate dosage of azathioprine or mercaptopurine. 

When monitoring azathioprine, mercaptopurine and the immunosuppressant methotrexate, patients should have regular blood tests, including a full blood count, liver and renal tests and c-reactive protein (CRP) while on treatment – at least every two weeks for the first month, monthly for the next three months, then three-monthly thereafter.

With any immunomodulator, patients and their carers should be warned to immediately report any signs or symptoms of bone marrow suppression, such as inexplicable bruising, bleeding or infection.