Chronic Inflammatory Bowel Diseases: New, Modern Treatment—An Expert Interview with Prof. Ehehalt

Prof. Dr. med. Robert Ehehalt is a renowned gastroenterologist and director of the Gastroenterology Practice in Heidelberg. His areas of expertise include the diagnosis and treatment of gastrointestinal and liver diseases, particularly inflammatory bowel disease (IBD), as well as colorectal cancer screening and nutritional medicine. Thanks to his extensive expertise and many years of experience, he is a recognized authority in this field and enjoys the trust of numerous patients.

As an adjunct professor of internal medicine at Heidelberg University, Prof. Dr. Ehehalt shares his expertise with medical students and also regularly gives lectures to fellow specialists. Through his membership in the American Gastroenterological Association, he maintains an international network and stays up to date on the latest scientific developments.  A particular focus of his practice is modern endoscopy. Using innovative procedures, including capsule endoscopy and the GI Genius™ smart endoscopy module, he enables a precise and minimally invasive examination of the entire gastrointestinal tract. The early detection of colorectal cancer through colonoscopies, as well as the immediate removal of polyps, play a crucial role in preventing serious diseases.

As director of the IBD Study Center, Prof. Dr. Ehehalt is actively involved in researching new treatment options and has access to innovative medications that can help many patients even before they are released to the market. In addition to medical treatment, he places particular emphasis on nutritional medicine, which often plays a crucial role as a complementary therapy. The gastroenterology practice in Heidelberg is certified as a specialty practice for inflammatory bowel diseases and enjoys an excellent reputation beyond the region. Patients appreciate not only Prof. Dr. Ehehalt’s high level of professional expertise but also his compassionate and empathetic manner, which consistently earns him top ratings in independent reviews.

There is a new corticosteroid-free therapy for chronic inflammatory bowel diseases—the editorial team of the Leading Medicine Guide had the opportunity to speak with Prof. Dr. Ehehalt about this.

 

Chronic inflammatory bowel diseases (IBD) are long-term, typically relapsing conditions of the gastrointestinal tract characterized by inflammation of the intestinal mucosa. The two most common forms are Crohn’s disease and ulcerative colitis, which differ in their extent and symptoms. While Crohn’s disease can affect the entire digestive tract, ulcerative colitis is limited to the large intestine. Typical symptoms such as diarrhea, abdominal pain, and weight loss significantly impair the quality of life of those affected. Despite intensive research, the exact causes are not yet fully understood; however, genetic factors, the immune system, and environmental factors play a central role. Thanks to modern diagnostic methods and new drug therapies, IBD can be treated more effectively, allowing many patients to lead a nearly normal life.

Chronic inflammatory bowel diseases (IBD), such as Crohn’s disease and ulcerative colitis, manifest through a variety of symptoms that can greatly impact the daily lives of those affected. 

“The inflammation associated with inflammatory bowel disease does not usually go away on its own. The disease is caused by polygenic factors, combined with environmental factors that ultimately trigger the condition. Depending on the disease, the entire gastrointestinal tract may be affected—in Crohn’s disease, from the mouth to the anus—while in ulcerative colitis, the other form of IBD, only the large intestine is affected. Symptoms vary depending on the location of the inflammation in the intestine. If the inflammation is in the large intestine, patients often experience diarrhea, bloody stools, abdominal cramps, and/or a sense of urgency to defecate,” explains Prof. Dr. Ehehalt.

In addition, many patients also complain of extreme tiredness and exhaustion, known as fatigue, which further impairs their quality of life. Weight loss and malnutrition are also common complications, as inflammation in the intestine hinders the absorption of nutrients. Some patients also experience additional symptoms such as joint pain, skin changes, or eye inflammation, which indicate the systemic nature of the disease. The course of the disease varies from patient to patient, with most experiencing a relapsing-remitting course. This means that symptoms occur in phases—during active phases of the disease, also known as flares, symptoms are often severe, while during remission phases (quiet phases) they decrease significantly or even disappear entirely. However, there are also patients in whom symptoms persist continuously, which can significantly impair quality of life. 

Without adequate treatment, serious complications can also arise as the disease progresses. These include, among other things, intestinal strictures that make bowel movements difficult, as well as fistulas, which can form inflammatory connections between the intestine and other organs. In particular, long-term ulcerative colitis also increases the risk of developing colorectal cancer. 

The causes of inflammatory bowel diseases (IBD), such as Crohn’s disease and ulcerative colitis, are complex and not yet fully understood. However, it is becoming increasingly clear that genetic, immunological, and environmental factors play a decisive role in the development and progression of these diseases.

Genetic factors play a role in susceptibility to IBD. Researchers have identified several genes associated with an increased risk of these diseases. “In chronic inflammatory bowel diseases (IBD), more than 300 susceptibility genes have already been identified that influence the risk of disease, including NOD2, ATG16L1, IL23R, and many others. These are genes that increase susceptibility to IBD but do not cause the disease on their own. They are therefore risk genes that, in combination with environmental factors, influence the likelihood of the disease developing. All of these genes are most likely related to the maintenance of the intestinal barrier. In IBD, there is not necessarily a disruption of the adaptive immune system, as is the case with an autoimmune disease, for example, but rather a disruption of the intestinal barrier. To put it simply, the intestinal barrier is more permeable, which is why commensal bacteria can find their way into the intestinal wall and lead to chronic inflammation. In addition, environmental triggers such as stress, frequent use of antibiotics, lack of sleep, smoking, and lack of exercise contribute to the onset of the disease,” explains Prof. Dr. Ehehalt. 

In healthy people, the immune system recognizes foreign invaders such as bacteria or viruses and fights them off. In people with IBD, however, this immune response is disrupted. The immune system overreacts to harmless substances in the gut, which can trigger chronic inflammation. This faulty immune response affects, among other things, the so-called T cells, which play a central role in regulating the immune response. This overreaction of the immune system causes inflammation to become chronic and damages the intestinal mucosa. 

The microbiome—the entire community of microorganisms living in the human body, particularly in the gut—plays a central role in the health of the gut and the entire body.

Prof. Dr. Ehehalt explains: “The microbiome likely plays a very important role in chronic inflammatory bowel diseases (IBD), such as Crohn’s disease and ulcerative colitis. A healthy microbiome contributes to a stable immune response, supports digestion, aids in the production of certain metabolites, and protects against harmful pathogens. In IBD patients, the microbiome is often disrupted. A reduced diversity of beneficial microbes and an overgrowth of bacteria that may be less stabilizing can lead to inflammation and dysregulation of the immune system. Ultimately, however, every microbiome is like a fingerprint—it varies from person to person. A decline in the diversity of the microbiome is a problem observed in industrialized nations. There are various theories regarding this; one is the so-called hygiene hypothesis: In modern, “more hygienic” societies, children may be exposed to a smaller number of different microbes and fewer infections, which ultimately “trains” the immune system less and can thus lead to increased susceptibility. The microbiome can be influenced by changing one’s diet, for example, by switching completely to a Mediterranean diet and no longer eating fast food. The Mediterranean diet is considered recommended. It is said to contribute to a particularly healthy gut flora with high diversity, while unbalanced convenience or fast-food products tend to have a negative effect. “It’s always better to eat fresh, varied foods,” he adds, and continues:

“In Germany, there are now an estimated 600,000 people with IBD, and this number is expected to rise to approximately 800,000 by 2030. Those affected are usually between 15 and 40 years old at the time of initial diagnosis, and today’s lifestyle has certainly contributed to the rising number of people affected. Factors cited include spending too little time in nature, possibly insufficient exposure to sunlight and thus lower vitamin D levels, too little physical activity, and, in some areas, potentially excessive hygiene practices. For example, one study suggests that people who had dogs during childhood are less likely to develop IBD than those who grew up without a dog or other pet. There is some evidence to support this—though the reliability of this evidence is still a matter of debate.”

Certain diets, such as the so-called elemental diet, or specialized dietary approaches like the microbiome-targeted diet or the low-FODMAP diet, aim, among other things, to influence the microbiome through targeted food intake. The elemental diet consists of easily digestible foods that can reduce the burden on the microbiome. The low-FODMAP diet, on the other hand, is designed to reduce fermentable carbohydrates in the gut that are associated with an impaired microbiome. Dietary changes aimed at restoring a healthy microbiome composition can be an important complement to drug therapy.

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FODMAP stands for Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols. These are specific short-chain carbohydrates and sugar alcohols that are poorly absorbed in the small intestine and therefore ferment in the large intestine.

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In recent years, treatment options for inflammatory bowel disease (IBD) have advanced considerably, and modern treatment approaches such as biologics, personalized medicine, and innovative dietary strategies have significantly improved outcomes for patients. 

“We’re talking about ‘advanced therapy’—that is, an advanced treatment that we offer patients. This includes approved medications that have nothing to do with cortisone (an anti-inflammatory drug), mesalazine (an anti-inflammatory agent), or azathioprine (an immunosuppressant). ‘Advanced therapy’ involves the use of biologics and so-called ‘small molecules,’ which specifically target certain molecules of the immune system that influence inflammatory processes in the gut. There are biologics that we’ve known about for 20 years, but we also have new biologics. Therapy with “small molecules” involves taking immunosuppressants in tablet form, with patients typically taking just one tablet a day to control the disease. These therapies are beneficial, on the one hand, because patients feel better quickly, and on the other hand, they are also suitable for achieving remission, since IBD is a recurrent disease. “This means these are therapies that are generally administered over several years,” said Prof. Dr. Ehehalt regarding “modern” forms of therapy.

In particular, the so-called TNF-alpha inhibitors (such as infliximab, adalimumab, and golimumab) have revolutionized the treatment of Crohn’s disease and ulcerative colitis since their introduction over 15 years ago by effectively suppressing TNF-alpha-mediated inflammatory reactions. But newer biologics as well, such as integrin inhibitors (e.g., vedolizumab) and interleukin inhibitors (such as ustekinumab, guselkumab, mirikizumab, and risankizumab), have yielded promising results by specifically intervening in the immune response and inhibiting inflammatory processes. These medications offer high efficacy, even in patients who were unable to achieve adequate disease control with conventional therapies. Particularly in severe forms of IBD, biologics have significantly improved patients’ quality of life and well-being and, in many cases, achieved remission that was previously unthinkable.

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The newest classes of medications—JAK-1 inhibitors, S1P receptor modulators, and IL-23 inhibitors offer promising options for the treatment of inflammatory bowel disease (IBD) such as Crohn’s disease and ulcerative colitis. These medications represent a new generation of therapies that specifically target the immune process and can positively influence the course of the disease.

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“These therapies can be used in all patients unless there is a contraindication. In certain medical situations, however, modern medications such as JAK inhibitors should not be used or should be used with caution—for example, if the patient has a cardiac arrhythmia or hypercholesterolemia (in which case the blood cholesterol level is too high). This means that the choice of therapy is highly individualized, because we must always consider the patient’s overall medical history and which medications they have taken in the past. We must also discuss with the patient what they want, and together we can make the right treatment decision. “IBD cannot truly be cured. However, the disease may go into what is known as remission—meaning the patient has no symptoms whatsoever, which is what we aim for with medication—but the disease persists for the rest of the patient’s life,” explains Prof. Dr. Ehehalt.

Complications of Inflammatory Bowel Disease 

“If the intestine is inflamed and the inflammation cannot be controlled, complications such as fistulas or strictures may occur, and in cases of chronically active IBD, the risk of cancer may increase. Chronic inflammatory diseases are often associated with one another, so a patient with IBD may also be more likely to suffer from other inflammatory conditions such as psoriasis or rheumatism, and finally, someone with a chronically active disease naturally becomes exhausted more quickly and is more susceptible to infections due to the persistent inflammation,” adds Prof. Dr. Ehehalt. 

In conclusion, Prof. Dr. Ehehalt emphasizes: “Modern medicine today offers numerous innovative treatment approaches with which we can significantly improve the quality of life for patients with chronic inflammatory bowel diseases. Early diagnosis, individually tailored treatment strategies, and a comprehensive understanding of the disease are crucial. Together with our patients, we seek the best possible treatment to enable them to live as symptom-free a life as possible.”

Thank you very much, Professor Dr. Ehehalt, for your insights on chronic inflammatory bowel diseases!