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Medical Author:

Adam Schoenfeld, MD

Medical Author:

George Y. Wu, MD, PhD

Medical Editor:

Jay W. Marks, MD

Jay W. Marks, MD

Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.

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In this Article

• What is Crohn's disease?
• What causes Crohn's disease?
• How does Crohn's disease affect the intestines?
• How is Crohn's disease different from ulcerative colitis?
• What are the symptoms of Crohn's disease?
• What are the complications of Crohn's disease?
• How is Crohn's disease diagnosed?
• How is Crohn's disease treated?
• Crohn's Disease Medications
• Anti-inflammatory medications
• 5-ASA (mesalamine) oral medications
• 5-ASA rectal medications (Rowasa, Canasa)
• Corticosteroids
• Budesonide (Entocort EC)
• Antibiotics
• Immuno-modulator medications
• Azathioprine (Imuran) and 6-mercaptopurine (6-MP, Purinethol)
• Infliximab (Remicade)
• Adalimumab (Humira)
• Certolizumab pegol (Cimzia)
• Natalizumab (Tysabri)
• Methotrexate
• Surgery in Crohn's disease
• Are there any recommendations for diet and supplementation for Crohn's disease?
• Conclusions
• Crohn's Disease At A Glance
• Pictures of Digestive Disease Myths - Slideshow
• Take the Quiz: Tummy Trouble Digestive Disorders
• Pictures of Diverticulitis (Diverticulosis) - Slideshow
• Find a local Gastroenterologist in your town

Methotrexate (Rheumatrex, Trexall)

Methotrexate (Rheumatrex, Trexall) is both an immuno-modulator and anti-inflammatory medication. Methotrexate has been used for many years in the treatment of severe rheumatoid arthritis and psoriasis. It has been helpful in treating patients with moderate to severe Crohn's disease who are either not responding to azathioprine and 6- MP or are intolerant of them. Methotrexate also may be effective in patients with moderate to severe ulcerative colitis who are not responding to corticosteroids, azathioprine, or 6-MP. It can be given orally or by weekly injections under the skin or into the muscles, but it is more reliably absorbed with the injections.

One major complication of methotrexate is the development of liver cirrhosis when the medication is given over a prolonged period of time (years). The risk of liver damage is higher in patients who also abuse alcohol or are severely obese. Although it has been recommended that a liver biopsy should be obtained in patients who have received a cumulative (total) methotrexate dose of 1.5 grams or higher, the need for such biopsies is controversial.

Other side effects of methotrexate include low white blood cell counts and inflammation of the lungs.

Methotrexate should not be used in pregnant women because of toxic effects on the fetus.

Surgery in Crohn's disease

There is no surgical cure for Crohn's disease. Even when all of the diseased parts of the intestines are removed, inflammation frequently recurs in previously healthy intestines months to years after the surgery. Therefore, surgery in Crohn's disease is used primarily for:

1. Removal of a diseased segment of the small intestine that is causing obstruction.
   
   
2. Drainage of pus from abdominal and peri-rectal abscesses.
   
   
3. Treatment of severe anal fistulae that do not respond to drugs.
   
   
4. Resection of internal fistulae (such as a fistula between the colon and bladder) that are causing infections.

Usually, after the diseased portions of the intestines are removed surgically, patients can be free of disease and symptoms for some time, often years. Surgery, when successfully performed, can lead to a marked improvement in a patient's quality of life. In many patients, however, Crohn's disease eventually returns, affecting previously healthy intestines. The recurrent disease usually is located at or near the previous site of surgery. In fact, 50% of patients can expect to have a recurrence of symptoms within four years of surgery. Drugs such as Pentasa or 6-MP have been useful in some patients to reduce the chances of relapse of Crohn's disease after surgery.

There is accumulating evidence in favor of post-operative therapy to delay recurrence in Crohn's disease. There appears to be some benefit of mesalamine in reducing the risk of post-op recurrence for up to 3 years. A recent study has also shown infliximab to be effective in preventing postoperative recurrence after ileocecal resection, though relapse may occur when therapy is stopped⁵.

Treatment strategies by severity and location of disease
(Based on the Second European Evidence-Based Consensus on the Diagnosis and Management of Crohn's Disease.)⁸

Mild to Moderate Active Disease

• Commonly treated with oral mesalamine 3.2-4 g daily or sulfasalazine for ileocolonic or colonic disease as 3-6 g daily in divided doses (this approach has more recently been reported to be not very effective).
  
  
• Budesonide (9 mg/day) is effective for disease confined to ileum and/or right colon.
  
  
• Proton pump inhibitors might help with symptomatic improvement in patients with upper gastrointestinal Crohn's disease.

Moderate to Severe Disease

• Prednisone 40-60 mg/day until resolution of symptoms.
  
  
• Appropriate antibiotic therapy for infection or abscess.
  
  
• Azathioprine and 6-MP are effective for maintaining a steroid-induced remission.
  
  
• Methotrexate 25 mg/wk is effective for steroid-dependent and steroid-refractory Crohn's disease.
  
  
• Infliximab, adalimumab, and certolizumab pegol are effective in the treatment of moderate to severely active disease in patients who have not responded to adequate therapy with a steroid or immunosuppressive agent.
  
  
• Natalizumab is effective in the treatment of patients with moderate to severely active CD who have had an inadequate response or are unable to tolerate conventional Crohn's disease therapy and anti-TNF antibody therapy.

Perianal or Fistulizing Disease

• Surgical drainage for abscess
  
  
• Otherwise, treated medically with antibiotics (metronidazole), immunosuppressives, or infliximab.

Are there any recommendations for diet, supplementation, or vaccinations for Crohn's disease?

Dietary changes and supplementation that may help control Crohn's disease.

• Since fiber is poorly digestible, it can worsen the symptoms of intestinal obstruction. Hence, a low fiber diet may be recommended, especially in those patients with small intestinal disease.
  
  
• A liquid diet may be of benefit when symptoms are more severe.
  
  
• Intravenous nutrition or TPN (total parenteral nutrition) may be utilized when it is felt that the intestine needs to "rest."
  
  
• Supplementation of calcium, folate and vitamin B12 is helpful when malabsorption of these nutrients is apparent.
  
  
• The use of anti-diarrheal agents (diphenoxylate and atropine [Lomotil], loperamide [Imodium]) and antispasmotics also can help relieve symptoms of cramps and diarrhea.

Vaccination recommendations for individuals with Crohn's disease

It is recommended that adults with inflammatory bowel disease generally follow the same vaccination schedules as the general population.

They should receive a single dose of Tdap, then Td booster every 10 years.

Women between the ages of 9 and 26 should receive 3 doses of HPV vaccine (and consideration should be given to older patients who are HPV negative on Pap smear). Men in the same age range should also consider being vaccinated given the increased risk of HPV with immunosuppression.

The influenza (flu) vaccine should be given annually to all patients (though the live intranasal vaccine is contraindicated in patients on immunosuppressive therapy).

One dose of pneumococcal vaccine should be given between age 19-26 and then revaccination after 5 years.

If not previously vaccinated, all adults should receive 2 doses of hepatitis A vaccine and 3 doses of hepatitis B.

Meningococcal vaccine is only recommended for patients with anatomic or functional asplenia, terminal complement deficiencies, or others at higher risk (college students, military recruits, etc).

Mumps/measles/rubella, varicella, and zoster vaccines are contraindicated for patients on biologic therapy, as they are all live vaccines.¹¹

Other factors that may affect Crohn's disease

A recent study found that active smoking is a risk factor for Crohn's disease, and passive smoking can also contribute to a worse prognosis. Therefore, smoking cessation should be advised among patients with Crohn's disease.¹¹

Osteoporosis with markedly reduced bone mineral densities has also increasingly been recognized as a significant health problem in patients with inflammatory bowel disease. Screening with a bone density study is recommended in postmenopausal woman, men > age 50, patients with prolonged corticosteroid use (> 3 consecutive months or recurrent courses), patients with personal history of traumatic fractures with minimal trauma, and patients with hypogonadism¹¹. Most patients with inflammatory bowel disease should be taking calcium and vitamin D supplements.