في المرحلة الحادة يعطى المريض كورتيزون بردنسولون 40مجم يوميا ثم ينزل عند هدوء المرض
للحفاظ على هدوء المرض يضاف علاج وقائي mesalamine ثمانمائة مجم ثلاث مرات
وهناك معلومات عن تفاصيل العلاجات بامكانك الاطلاع عليها في السطور التالية
Medical Care
- Diarrhea
- Chronic diarrhea responds well to antidiarrheal agents such as loperamide (2-4 mg), diphenoxylate with atropine (1 tab), and tincture of opium (8-15 gtt). Such agents may be administered up to 4 times daily but should not be given to patients with active colitis because of the risk of developing toxic megacolon.
- Patients with terminal ileal disease cannot absorb bile acids, which can lead to secretory diarrhea in the colon. These patients benefit from bile acid sequestrants (eg, cholestyramine [2-4 g], colestipol [5 g] bid/tid ac). Those who have extensive ileal disease or resection of more than 100 cm of ileum have defective bile salt absorption and develop steatorrhea. These patients benefit from a low-fat diet and medium-chain triglyceride preparations. Bile sequestrants exacerbate this type of diarrhea.
- Diarrhea may also develop because of bacterial overgrowth, short-bowel syndrome, and lactase deficiency.
- Abdominal cramps may be reduced with propantheline (0.125 mg), dicyclomine (10-20 mg), or hyoscyamine (0.125 mg). These drugs should not be used if a bowel obstruction is considered possible.
- For colon and small-bowel inflammation, anti-inflammatory drugs or antibiotics are helpful.
- Sulfasalazine is mainly useful in colonic disease because the active compound, 5-aminosalicylic acid (5-ASA), is released in the large bowel by bacterial degradation of the parent compound. Sulfasalazine does not alleviate small-bowel disease. Products such as mesalamine (Asacol) that release 5-ASA in the distal small bowel secondary to pH changes are more useful in patients with small intestinal Crohn disease. Long-term maintenance with mesalamine (800 mg tid) may delay clinical relapse. Sulfasalazine does not have an additive effect or a steroid-sparing effect when used in conjunction with corticosteroids. In contrast to its action in UC, it does not seem to maintain remission in Crohn disease.
- A short course of steroid therapy is indicated in patients with severe systemic symptoms (eg, fever, nausea, weight loss) and in those who do not respond to anti-inflammatory agents. Prednisone (40-60 mg/d) is generally helpful in acute inflammation. Once remission is achieved, slowly taper steroids (5-10 mg q1-2wk).
- In patients who relapse after withdrawal of steroids, other treatment options are required. Steroids are not indicated for maintenance therapy because of serious complications such as aseptic necrosis of the hip, osteoporosis, cataract, diabetes, and hypertension.
- In patients with a tender palpable mass, exclude an underlying abscess before starting steroids. Adding antibiotics is always beneficial if coexisting infection is considered likely.
- Consider immunosuppressants such as azathioprine (2 mg/kg/d) or its active ****bolite, 6-mercaptopurine (6-MP), if steroid withdrawal proves difficult. Response is usually observed within 3-6 months. Careful supervision is needed because of the risk of bone marrow suppression.
- If medical therapy fails, surgical resection of the inflamed bowel, with restoration of continuity, is indicated. Urgent surgery may be required in rare cases of sustained or recurrent hemorrhage and toxic megacolon. Partial small bowel obstruction may sometimes be treated conservatively with intravenous hydration, nasogastric suction, and parenteral nutrition if there is no evidence of adhesion or strangulation.
- Fistulae
- Fistulae between bowel loops (eg, ileoileal, ileocecal, ileosigmoid) are usually benign and may not produce any major problems.
- Enterovesicular, enterocutaneous, cologastric, and coloduodenal fistulae are more serious. Surgical intervention is rarely required unless fistulae are complicated by progressive obstruction or abscess formation or a large segment of bowel is bypassed, leading to severe diarrhea and malabsorption. Otherwise, medical management is used to treat underlying infections and symptoms with oral metronidazole (1 g/d) for at least 1-2 months. Ciprofloxacin confers additional benefit if no improvement occurs
- Anti****bolites are beneficial in reducing drainage and closing fistulae in 30-40% of patients. Total parenteral nutrition (TPN) and bowel rest may promote fistula healing during medical therapy.
- New medical therapies
- Anti–tumor necrosis factor (TNF) antibody
- TNF, a key inflammatory cytokine and mediator of intestinal inflammation, is expressed prominently in IBD. Infliximab is a chimeric mouse-human monoclonal antibody against TNF and shows promise in Crohn disease. It blocks TNF in the serum and at the cell surface, leading to the lysis of TNF-producing macrophages and T cells.
- In one study, nearly 65% of refractory cases of Crohn disease responded well to treatment with infliximab (5 mg/kg), and a third went into complete remission. Patients who relapsed after initial response responded again to further infusions. Infliximab is also effective in patients who have refractory perianal and enterocutaneous fistulae. On average, the effect lasts for 12 weeks. Important adverse effects include the development of a lupuslike syndrome and an increased incidence of tuberculosis. Anti–double-stranded DNA is not always associated with clinical lupus. An added benefit of infliximab treatment is the ability to possibly taper the prednisone dose, which will decrease further adverse effects.
- Unfortunately, infliximab is immunogenic, and repeated administration may result in the development of antibodies to infliximab that lead to infusion reactions, loss of efficacy, and delayed hypersensitivity reactions.
- Two anti-TNF agents, adalimumab and certolizumab, may be less immunogenic than infliximab and have shown efficacy in the treatment of Crohn disease that is refractory to standard medical treatment of corticosteroids and immunomodulatory agents.
- Adalimumab is a recombinant human IgG1 monoclonal antibody that binds with high affinity and specificity to human soluble TNF-alpha but not to lymphotoxin (TNF-beta). Results have shown that the immunogenicity of adalimumab is low compared to the chimeric mouse-human monoclonal antibody infliximab.
- Two placebo-controlled trials, CLASSIC I and CLASSIC II, showed that adalimumab was effective for both induction and maintenance of remission in patients who were previously naïve to anti-TNF therapy. The CHARM trial demonstrated the same effect in a mixed population of patients who either were naïve to infliximab therapy or had previously been on infliximab therapy. In patients who had lost response or become intolerant of infliximab, the GAIN trial results showed a benefit from adalimumab therapy induction with remission at 4 weeks. Furthermore, an open label study conducted in France that assessed the long-term efficacy and safety of adalimumab maintenance therapy in this population showed that it was well tolerated and effective in maintaining clinical remission in patients with Crohn disease with lost response or intolerance to infliximab.
- Certolizumab pegol, a humanized Fab'antibody fragment conjugated to polyethylene glycol, has also demonstrated efficacy in maintaining remission in patients with moderately to severely active Crohn disease who previously responded to induction therapy with the same agent (PRECISE trial). However, data only covered a 6-month period.
- Immunosuppressive agents: Tacrolimus may be effective in treating Crohn disease.
- Mycophenolate mofetil acts by inhibiting a de novo pathway of purine synthesis in lymphocytes, leading to intracellular depletion of guanosine monophosphate. This results in the suppression of cytotoxic T cells and formation of antibodies by activated B cells. A dose of 500 mg twice a day in 2 divided doses is well tolerated by patients and can be used to reduce the steroid dose.
- Anti-inflammatory cytokines: Interleukin 10 (IL-10) and interleukin 11 (IL-11) are anti-inflammatory cytokines and have been found by some researchers to elicit a moderate response in Crohn disease; however, more trials are needed.
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18-12-2008, 01:55 PM
La maladie de Chrone
العرض العادي
