Current treatment modalities in active Crohn's disease

The aetiology of Crohn's disease is unknown and, therefore, no curative treatments are currently available. Crohn's disease treatment requires knowledge of several variables affecting patient's responsiveness including: characteristics of the disease and of the host, as well as the specific purposes of treatment and the characteristics of the effective drugs. Currently available drugs for active Crohn's disease include: a) old drugs (oral/topical salicylates, conventional steroids); b) old drugs with a new face (immunosuppressives, antibacterial drugs); c) new drugs (budesonide, anti-cytokines/cytokines, probiotics). Among the old drugs, corticosteroids (1 mg/kg) are the most effective, with a 65-85% induction of remission, when compared to high dose sulphasalazine (3-5 g/day) (12%) and 5-aminosalicylic acid (4 g/day) (25%). The following drugs represent current treatment modalities in steroid/refractory active Crohn's disease. Immunosuppressives, including azathioprine (2-2.5 mg/kg) and 6-mercaptopurine (1-1.5 mg/kg) are less effective than steroids (30-40% vs 65-85%), but in chronic active Crohn's disease they show a 76% "steroid-sparing" effect and 63% fistula closure. The reported efficacy of methotrexate (25 mg/kg) and cyclosporine A in fistulous Crohn's disease needs to be confirmed. Antibiotics, such as metronidazole and ciprofloxacin (1 g/day) are effective in perianal or colonic active Crohn's disease. Budesonide, a steroid with low systemic absorption, shows an efficacy comparable to prednisone in active small bowel Crohn's disease. Bowel rest and enteral feeding are effective in active Crohn's disease. To summarize, conventional steroids still represent the most effective drugs in active Crohn's disease. However, refractory disease, steroid-dependence, drug-side effects and/or complications may require two main alternative management strategies: a) surgical resection in localized or primary Crohn's disease; b) alternative drugs in extensive or recurrent Crohn's disease.