Management of refractory inflammatory bowel disease

Numerous factors may contribute to refractory IBD and need to be addressed systematically. All patients require an accurate diagnosis of specific IBD type, and documentation of both disease activity and extent is crucial for management. Complications, such as strictures or abscesses, need to be recognized and treated appropriately. Enteric infections mimicking or exacerbating IBD should be excluded. Optimizing medication doses and stepwise combination and sequential treatment strategies are keys to successful medical therapy. Drug intolerances with paradoxical side effects should be considered. Patients with chronic diseases like IBD may not adhere to medical therapy, and this possibility needs to be addressed with all refractory patients. Both conventional and cyclooxygenase-2-type nonsteroidal anti-inflammatory drugs should be discontinued in patients with refractory IBD. The role of smoking and nicotine replacement in IBD needs to be understood. Lastly, surgery very well may be the appropriate course for patients if refractory disease persists despite optimal medical management.