Navigating Inflammatory Bowel Disease Treatment

Keeping symptoms at bay is important for anyone with inflammatory bowel disease (IBD)—an umbrella term for ulcerative colitis and Crohn’s disease, two conditions that cause chronic inflammation of the digestive system. That inflammation can lead to diarrhea and abdominal cramping and pain.

In the past, doctors relied on symptoms or invasive testing to gauge how well a medication, a primary treatment for IBD, was working. Now, IBD experts understand that the gastrointestinal tract can be inflamed and not trigger symptoms, yet still cause damage.

Inflammation from IBD that isn’t properly managed raises one’s risk for colon cancer and complications, including strictures (narrowing of the intestines). Preventing inflammation also brings long-term benefits by helping a person with IBD avoid surgery when other treatments are unsuccessful.

Today, IBD specialists are increasingly focused on staying ahead of symptoms. This often means adjusting a medication dose to bring down inflammation. The goal, explains Jill Gaidos, MD, a Yale Medicine gastroenterologist, is “mucosal healing,” which is a clinical standard that means the inner lining of the intestine (mucosa) is not inflamed and looks normal when viewed via imaging tests.

This is all good news for the estimated 600,000 to 900,000 Americans who have ulcerative colitis, and about 500,000 with Crohn’s. Ulcerative colitis involves damage to areas of the rectum and the inner lining of the colon, while Crohn’s may occur anywhere in the digestive tract, from the mouth to the anus.

Although the exact cause of IBD is unknown, it is thought to stem from an abnormal immune response that triggers inflammation. Genetics, environmental factors, and the microbiome (bacteria, viruses, fungi, and other microbes that live in the gastrointestinal tract) may also be involved. Neither ulcerative colitis nor Crohn’s disease has a cure, but a greater understanding of IBD and emerging treatments are benefiting both adult and pediatric patients.

Below, we talk with Dr. Gaidos and Danya Rosen, MD, a Yale Medicine pediatric gastroenterologist, about developments in managing IBD.

When someone is diagnosed with IBD (often based on a colonoscopy), one of the first goals is to identify the most appropriate medication (more on this below). Along with that, Dr. Gaidos discusses treatment objectives.

“In the short term, we want them to feel better. We call this clinical remission, and it means the symptoms have gone away,” she says. “I tell patients that this is feeling the way they did before they were diagnosed with inflammatory bowel disease.”

The secondary goal, she adds, is ensuring that inflammation has improved by checking a blood biomarker called C-reactive protein. (A biomarker is a biological molecule found in blood that provides information about health or disease.)

“This biomarker goes up when there's inflammation in the body. It's not specific to inflammation in the intestines, however. It can go up if someone has inflammatory arthritis or an inflammatory skin condition, but it can also be a marker of intestinal inflammation,” Dr. Gaidos says.

Another biomarker IBD specialists often check is fecal calprotectin, which is found in a stool sample and can indicate intestinal inflammation. “I will get a test for this before someone starts a medication and then check it again in three months to see if the number has gone down. This allows us to make sure we are heading in the right direction,” she says.

Lastly, the long-term goal is mucosal healing. “For Crohn’s disease, there may still be a little redness in the intestines, but we don't want to see any deep ulcers,” Dr. Gaidos says. “Usually, we’ll do a colonoscopy six to 12 months after starting medication to check for mucosal healing.”

The goal of eliminating inflammation and achieving mucosal healing is a change in thinking, notes Dr. Rosen, who sees patients at Yale New Haven Children's Hospital. “In the past, when we had a patient with IBD, if they felt well and their quality of life was getting better, but they still had abnormalities in blood work or stool testing that indicated inflammation, we wouldn’t focus on those numbers,” she says.

Now, however, if signs of inflammation appear in biomarkers, the medication is immediately adjusted to try and stay ahead of the inflammation before it causes symptoms, Dr. Rosen explains. “If we do this, we can prevent inflammation from causing scar tissue to develop, which means kids with IBD are much less likely to need surgery at some point in their lives,” she says.

Another tool, known as bedside intestinal ultrasound, allows doctors to immediately check a patient for intestinal inflammation, rather than relying on tests, including colonoscopy, blood tests, or a stool sample for the same information.

Physicians in Europe, Canada, and Australia have been using this technology, also called point-of-care ultrasound, or intestinal ultrasound, for decades, but the practice is new to the United States.

With this procedure, the provider places an ultrasound probe on a patient’s stomach to evaluate their intestines and look for signs of active inflammation. It can also show strictures, abscesses, and other complications.

Dr. Gaidos recently became the first provider to offer intestinal ultrasound in Connecticut, and other Yale Medicine IBD specialists are expected to start using the technology, which requires a year-long training program and certification.

“This ultrasound is very convenient for patients and offers us imaging that is nearly as good as a colonoscopy,” Dr. Gaidos says. “The limitation is that we can’t see the rectum very well because it’s deep inside the pelvis. So if someone has proctitis, which is inflammation in the lower part of the intestine, ultrasound isn’t as useful as other monitoring methods. It also doesn’t take the place of a colonoscopy to look for polyps or colon cancer.”

Medication is the primary treatment for IBD. It can be taken as a pill or delivered by infusion or injection. These medications work in different ways, ranging from corticosteroids for short-term relief of flare-ups to biologics, a drug class that blocks the body’s inflammation response, to Janus kinase (JAK) inhibitors, which block inflammation signals in the body’s cells.

In the last few years, the Food and Drug Administration approved three new drugs for IBD:

• Risankizumab, or Skyrizi®, for Crohn’s disease and ulcerative colitis. This is a biologic delivered through three IV infusions, followed by regular subcutaneous (shots given under the skin) injections.
• Miririkizumab, or Omvoh™, for ulcerative colitis. This is a biologic delivered intravenously, followed by subcutaneous maintenance injections.
• Guselkumab, or Tremfya™, for Crohn’s disease and ulcerative colitis. This is a biologic delivered through three IV infusions or three subcutaneous injections followed by maintenance injections.
• Upadacitinib, or Rinvoq®, an oral therapy for both ulcerative colitis and Crohn’s disease is a JAK inhibitor.

Surgery is sometimes necessary when complications like fistulas, abscesses, or blockages occur, or when medication is no longer effective. For Crohn’s disease, someone may need surgery to remove narrowed sections of bowel or address other issues. In severe ulcerative colitis, removing the colon and rectum (and creating new ways for stool to leave the body) can effectively treat the disease, but some patients develop recurrent inflammation in the remaining intestines following surgery.

Clinical trials testing new types of treatment are another option for patients. “We have several trials available at Yale looking at new therapies for inflammatory bowel disease,” Dr. Gaidos says. “Often, people think of clinical trials as a last-ditch effort, after they’ve tried everything available on the market. But many trials exclude patients who have been on more than two or three different therapies for their IBD. In those cases, I tell patients if we’re going to switch treatments, let’s try one that’s in a trial. That way, if it doesn't work, we have the other approved medications that we can go back to.”