Treatments: strategy guides
Inflammatory bowel disease (IBD) treatment has expanded from older anti inflammatory drugs to a wide range of advanced targeted therapies. The overall goal is not only symptom relief but also quiet inflammation seen on tests and scopes. Treatment plans are usually built stepwise, based on disease severity and risk of complications, but newer guidelines support earlier use of advanced therapies in many moderate to severe cases. (pubmed.ncbi.nlm.nih.gov)
Key Takeaways
IBD therapy is built around clear targets, such as symptom control and healing seen on colonoscopy, using a treat to target approach. (pubmed.ncbi.nlm.nih.gov)
Mild ulcerative colitis often starts with aminosalicylates (5 ASA), sometimes with rectal therapy, while Crohn’s usually needs other options. (gastro.org)
Corticosteroids are used for short term flare control, not as long term maintenance, because of significant side effects. (journals.lww.com)
Immunomodulators and biologics, with or without small molecules, form the backbone of maintenance treatment for moderate to severe disease. (journals.lww.com)
Newer oral targeted drugs, such as Janus kinase (JAK) inhibitors and sphingosine 1 phosphate (S1P) modulators, give additional options when injections or infusions are not preferred or have failed. (pubmed.ncbi.nlm.nih.gov)
Treatment sequencing is increasingly personalized, based on disease type, severity, prior drug response, safety profile, and patient priorities. (journals.lww.com)
How IBD treatment is organized
Modern IBD care follows a treat to target strategy. The care team sets clear goals, such as relief of daily symptoms, normal blood and stool markers, and healing on endoscopy, then adjusts medicines until those goals are met and maintained. (pubmed.ncbi.nlm.nih.gov)
Treatment choices depend on:
Whether the diagnosis is Crohn’s disease or ulcerative colitis
How severe and how extensive the inflammation is
The risk of complications, such as strictures, fistulas, or hospitalizations
Other health conditions, infection risk, age, and pregnancy plans
Historically, many people were treated with a step up approach. Mild drugs were tried first, then stronger medicines were added only after repeated flares or complications. With better data, guidelines now encourage earlier use of advanced therapies in many patients with moderate to severe ulcerative colitis and Crohn’s disease, especially when high risk features are present. (journals.lww.com)
Main medication classes
Aminosalicylates (5 ASA)
Aminosalicylates include mesalamine and related drugs. They act locally on the colon lining to reduce inflammation.
Main role is mild to moderate ulcerative colitis, for both induction and maintenance of remission.
Used as oral pills and as rectal suppositories or enemas for disease in the rectum and left colon.
They are not very effective for Crohn’s disease, so use there is limited. (gastro.org)
Because of their safety profile, 5 ASA drugs are often the first treatment offered for mild, low risk ulcerative colitis.
Corticosteroids
Corticosteroids (such as prednisone, methylprednisolone, and budesonide) quickly calm inflammation.
Used to treat flares in both Crohn’s disease and ulcerative colitis.
Budesonide targets specific gut areas with fewer body wide side effects and is used in some mild to moderate cases.
Systemic steroids can cause weight gain, bone loss, infection risk, mood changes, and many other problems, so they are short term only, not maintenance drugs. (journals.lww.com)
A common goal is to achieve steroid free remission, then use other medicines to maintain control.
Immunomodulators
Immunomodulators adjust the immune response more broadly than targeted biologics.
Thiopurines include azathioprine and 6 mercaptopurine.
Methotrexate is used mainly in Crohn’s disease. (journals.lww.com)
They have a slow onset, often taking months to work, and require regular blood tests to monitor liver function, blood counts, and rare but serious risks such as lymphoma and skin cancer.
Today, thiopurines and methotrexate are used less often as first line monotherapy for moderate to severe IBD, and more often as:
Steroid sparing agents in some cases
Combination partners with anti tumor necrosis factor (anti TNF) biologics to improve durability in selected patients
Biologics and targeted small molecules
These medicines directly block key steps in the immune pathway that drives IBD.
Anti TNF agents
Anti TNF drugs include infliximab, adalimumab, certolizumab pegol, and golimumab. They have long track records in both Crohn’s disease and ulcerative colitis. (journals.lww.com)
They are often used for:
Moderate to severe luminal disease
Fistulizing and perianal Crohn’s disease
Acute severe ulcerative colitis in hospital
Anti integrin therapy
Vedolizumab blocks lymphocyte trafficking into the gut and is considered a gut selective therapy. It has a strong safety profile, including in older patients and those with infections or malignancy concerns, although onset of effect can be slower. (academic.oup.com)
IL 12/23 and IL 23 inhibitors
Ustekinumab targets interleukin 12 and 23 and is effective for both Crohn’s and ulcerative colitis.
Newer IL 23 only inhibitors, such as risankizumab for Crohn’s disease and mirikizumab or guselkumab for ulcerative colitis, offer additional advanced options and are grouped among higher efficacy choices in recent ulcerative colitis guidelines. (gastro.org)
JAK inhibitors
Oral Janus kinase (JAK) inhibitors include tofacitinib and upadacitinib. They work quickly and are used in moderate to severe ulcerative colitis, including in people who have already tried biologics. Upadacitinib is also approved for moderate to severe Crohn’s disease. (pubmed.ncbi.nlm.nih.gov)
They carry important safety warnings related to serious infections, blood clots, heart events, and certain cancers, so careful selection and monitoring are needed.
S1P receptor modulators
Sphingosine 1 phosphate (S1P) receptor modulators, such as ozanimod and etrasimod, are once daily oral options for moderate to severe ulcerative colitis. (news.bms.com)
They work by trapping certain white blood cells in lymph nodes so fewer reach the gut. Heart rhythm, eye health, and liver tests are checked before and during use.
Topical rectal therapies
Suppositories, foams, and enemas that contain 5 ASA or steroids treat inflammation in the rectum and left colon directly.
They are especially important in:
Ulcerative proctitis or left sided ulcerative colitis
As add on therapy to oral 5 ASA for better control
Guidelines show that rectal 5 ASA can be more effective than rectal steroids for induction in mild disease, but steroids remain helpful when 5 ASA is not tolerated or is ineffective. (gastro.org)
Antibiotics and supportive medicines
Antibiotics are not primary anti inflammatory therapy in IBD, but they are often used for:
Perianal Crohn’s disease
Abscesses or infections
Pouchitis after surgery
Other medicines, such as antidiarrheals, bile acid binders, and antispasmodics, may ease symptoms but do not treat underlying inflammation.
Typical sequencing in ulcerative colitis
A common pattern, based on guideline frameworks, looks like this: (journals.lww.com)
Mild proctitis or left sided disease
- Rectal 5 ASA, often combined with oral 5 ASA.Mild extensive disease
- Oral 5 ASA at adequate dose, plus rectal 5 ASA when possible.If 5 ASA is not enough
- Add short course oral or rectal steroids, or budesonide formulations.Moderate to severe or 5 ASA failure
- Start an advanced therapy.
- Options include anti TNF, vedolizumab, ustekinumab, IL 23 inhibitors, JAK inhibitors, or S1P modulators.
- Newer guidelines support using advanced therapies earlier rather than cycling through repeated steroids. (gastro.org)Hospital level severe flares
- Intravenous steroids first, then rescue with infliximab or cyclosporine if response is poor.
Typical sequencing in Crohn’s disease
Crohn’s treatment depends strongly on disease location, severity, and complications. (journals.lww.com)
A simplified sequence:
Mild ileocecal or colonic disease without high risk features
- Budesonide or a short steroid course for induction.
- Consider early introduction of a biologic in selected cases.Moderate to severe luminal disease or high risk features
- Early biologic therapy, often anti TNF or ustekinumab or vedolizumab, sometimes combined with an immunomodulator.Fistulizing or perianal disease
- Anti TNF therapy is often first choice, plus antibiotics and surgical or radiologic support when needed.After biologic failure or intolerance
- Switch within or between classes, for example from an anti TNF to ustekinumab, risankizumab, vedolizumab, or a JAK inhibitor such as upadacitinib, depending on regulatory approvals and safety profile. (academic.oup.com)
Throughout care, the team uses biomarkers, imaging, and endoscopy to check if treatments are truly achieving the agreed targets, and adjusts therapy when they are not.
FAQs
Are 5 ASA drugs enough on their own for Crohn’s disease?
Most guidelines find limited benefit of 5 ASA in Crohn’s disease, especially for maintaining remission, so they are rarely central long term therapy. Other agents, such as budesonide, biologics, and immunomodulators, are usually needed for ongoing control. (journals.lww.com)
Why do doctors try to avoid long term steroids?
Steroids control symptoms quickly but cause many time linked side effects, including osteoporosis, diabetes, infections, mood changes, and eye problems. Because of this risk profile, they are used as short term bridge therapy while safer maintenance medicines take effect. (journals.lww.com)
How do teams choose between biologics and newer oral drugs?
Choice depends on how active the disease is, which drugs have been tried before, other health issues, pregnancy plans, route preferences, and safety concerns. For example, gut selective vedolizumab may fit some higher infection risk patients, while JAK inhibitors or S1P modulators offer oral options but need careful safety monitoring. (gastro.org)
Can treatment be stepped down after remission?
If deep remission is sustained, some people can reduce steroid use and, in selected cases, simplify from combination therapy to biologic or small molecule alone. Decisions are individualized and guided by risk of relapse, prior history, and ongoing monitoring. (pubmed.ncbi.nlm.nih.gov)