Treatment plans for Crohn’s disease can be complex. Here are the top 5 categories of Crohn’s medications.
Of course the first place to start is with an open and honest conversation with your gastroenterologist. Your gastroenterologist can help you weigh the pros and cons of many Crohn’s medications and non-medication treatment options. The goal of all Crohn’s disease treatment is to achieve and maintain remission (control or resolution of symptoms).
Examples: Azulfidine, Asacol, Balsalzide, Delzicol, Pentasa, Lialda, Mesalamine, Sulfalazine
Aminosalicylates contain 5-aminosalicylic acid (5-ASA) which helps reduce inflammation in the intestine wall. It is possible to take these drugs orally or rectally (a suppository).
Aminosalicylates are most effectively used in combatting other types of IBD, but may be used in conjunction with other medications to treat Crohn’s disease and limit inflammation.
Typically, these medications are handled well by the body and have not been associated with an increased risk of infection or cancer. Some aminosalicylates contain sulfa (e.g., sulfasalazine (Azulfidine)). If you have a sulfa allergy, be sure to share that information with your doctor. These medications are considered safe to take during pregnancy.
Potential side effects
- Abdominal pain
- Loss of appetite
- Diarrhea (in less an 1% of users)
- Kidney injury (rare – but those with kidney damage should be aware and speak with their clinician)
Specific side effects
Decreased sperm production may occur. Sperm count normalized when medication is discontinued.
Rarely associated with pancreatitis (inflammation of the pancreas)
Diarrhea is a common side effect. Take with food to reduce diarrhea.
Rare side effects include hair loss, pancreatitis, or pericarditis (inflammation of the tissue around the heart)
Examples: Prednisone (Deltasone), budesonide (Entocort), Uceris, hydrocortisone, methylprednisone, Contenema, Proctofoam-HC
Since their approval in the 1950s, corticosteroids have been used for acute treatment of flare-ups. They are powerful, fast-acting anti-inflammatories that can reduce inflammation anywhere in the body including the intestine, joints, skin, and eyes. Corticosteroids disrupt the body’s ability to start and/or maintain an immune response; they suppress the immune system.
Sometimes referred to as simply “steroids,” these medications are different from the types used in weight-lifting or sports to add muscle.
Corticosteroids are not typically longterm Crohn’s medications (though they may be used for weeks or months at a time) – and are best used for short-term symptom control. These medications do not prevent complications or advancement of Crohn’s disease, and are coupled with a large number of side effects and risks that increase with use.
NOTE: 20-30% of people with acute Crohn’s symptoms will not respond to corticosteroids. Most people will notice improvement within a few days of beginning the medication.
20-30% of people will not respond to corticosteroids
Special oral preparations
Corticosteroids may be taken in pill form, and those pills may have different external coatings to delay the breakdown of the medication. For example, Budesonide-MMX (Uceris) and others will not breakdown until the Crohn’s medications reach the colon, and can be used strategically to target specific inflammation.
Special rectal preparations
There are 3 types of rectal preparations of Crohn’s medications:
- Enemas, and
- Rectal foams
They are used to treat local inflammation of the anus, rectum, and sigmoid colon. These medication administrations are more targeted and minimize whole-body exposure, which reduces the number of risks and side effects associated with medication.
Potential side effects:
Since corticosteroids suppress the immune system, people are more prone to get infections when taking these medications. In particular, people are more susceptible to thrush (yeast infection of the mouth), urinary tract infections (UTI), and infections of the female reproductive organs.
Other potential side effects include:
- High blood pressure (hypertension)
- “Moon face” (an increasingly round face)
- Weight gain
- High blood sugar
- Mood swings
- Weakened bones
- Psychosis and other psychiatric symptoms
Specific side effects:
Longterm use of suppositories is associated with the weakening of the ano-rectal muscles
Purpose: Suppress immune system
Examples: Azathioprine (Imuran), 6-mercaptopurine (Purinethol), methotrexate, cyclosproine (Sandimmune, Neoral), tacrolimus (Prograf)
Immunomodulators have been used since the late 1960s to inhibit the activity of the immune system so that it cannot cause persistent inflammation. Often, these medications are used along with a corticosteroid when Crohn’s disease is active, such as during a flare, to speed up the body’s response. This is a common Crohn’s medications strategy because lower doses of the steroid are required, so people experience fewer side effects. For this reason, immunomodulatrs are sometimes called “steroid-sparing” drugs.
Because immunomodulators reduce the activity of your immune system, you may be more prone to illness as your body can’t fight infection as readily. Because of this, contact your doctor if you experience a fever, chills, or a sore throat. Additionally, blood tests should be performed frequently to monitor your bone marrow, liver, and kidneys.
NOTE: Methotrexate should be avoided by pregnant women AND by both men and women several months before conception to avoid birth defects. Pregnant women, or those hoping to become to, should speak with their doctors.
Immunomodulators are used if you:
- are maintaining a Crohn’s remission
- have fistulas (“tunnels” between internal the intestines and other organs)
- experience side effects with corticosteroids
- have a steroid-dependent disease or frequently take steroids
- do not respond to aminosalicylates, antibiotics, or corticosteroids
- have perineal disease that does not respond to antibiotics
Oral Medication delivery and notes
Azathiprine (Imuran, Azasan) and 6-mercaptopurine (Purinethol) are chemically-similar Crohn’s medications that are used commonly to treat IBD. These medications can be taken orally.
The full effect of these medications may not be evident for 3-6 months after starting the course of treatment. For this reason, if you are experiencing side effects or not progressing as you would expect, it is important to speak with your doctor. If you are new to the treatment, the medication may not have achieved full effect.
Other medications and notes
Cyclosporine A (Sandimmune, Neoral) and tacrolimus (Prograf), medications used during organ transplants, are also commonly prescribed Crohn’s medications. Cyclosporine A has a considerably more rapid onset (one to two weeks) than other medications, however, it must be given intravenously and at high dosese.
In addition to oral preparations, it is possible to apply tacrolimus topically – particularly if you experience Crohn’s disease of the mouth or perineal area.
Methotrexate (MTX, Rheumatrex, Mexate) also reaches full effectiveness more quickly than azathioprine. It is given by weekly injections — and is most effective for people with Crohn’s disease that has not responded to other treatments and who may not be able to tolerate other immunosuppressants.
Potential side effects
As mentioned above, because the immune system activity is reduced, there is a higher risk for infection. Common short term risks include inflammation of the liver or pancreas. Also, bone marrow may be suppressed.
Long term use of immunosuppressants is rarely associated with infections and cancers (including lymphoma and skin cancer).
Common side effects including nausea and vomiting.
Specific side effects
Azathioprine and 6-MP (Imuran, Azasan and Purinethol)
Infrequent side effects include:
- malaise and general feelings of illness
- canker sores in the mouth
- joint pain
Less common side effects are pancreatitis and bone marrow suppression. These may increase the risk of infection or bleeding.
Upon discontinuation of this medication, it may take the body several weeks to return to normal levels of blood cell production.
Cyclosporine and tacrolimus (Sanimmune, Neoral, Prograf)
Infrequently reported side effects include:
- decreased kidney function
- increased cholesterol levels and high blood pressure
- sleep problems
- mild tremors swollen gums
- tingling of the fingers and feet
- increased facial hair
Methotrexate (MTX, Rheumatrex, Mexate)
Infrequently reported side effects include low white blood cell count and flu-lie symptoms. More serious side effects include scarring of the liver and lung inflammation. Diabetes, being overweight, and drinking alcohol may make the liver scarring worse.
Purpose: Suppress immune system and reduce intestinal bacteria
Examples: Metronidazole (Flagyl), ciprofloxacin (Cipro)
Antibiotics are frequently used as a primary treatment for IBD and Crohn’s disease despite the fact that there is no specific infection causing these illnesses. Researchers believe that antibiotics limit Crohn’s symptoms by reducing intestinal bacteria and suppressing the immune system.
For people with fistulas or recurring abscesses near the anus, antibiotics are an effective long-term treatment strategy. Antibiotics are NOT considered useful for people with ulcerative colitis (except in the case of toxic megacolon).
Both metronidazole (Flagyl) and ciproflxacin (Cipro) are broad-spectrum antibiotics that fight a range of bacteria. Metronidazole has been extensively studied in conjunction with IBD; it is equally as effective as sulfasalazine when the disease impacts the colon. It reduces the recurrence of Crohn’s in the three months following ileum resection surgery. And, it suppressed overgrowth of C. difficile, an inflammation causing bacteria. Despite these advantages, Cipro is commonly used to treat Crohn’s because it is far safer than metronidazole.
Special consideration for antibiotics
Antibiotics DECREASE the effectiveness of oral contraceptive medications, like birth control pills.
Antibiotics can dangerously interfere with anticoagulants such as warfarin (Coumadin). The blood may become too thin, which increases the risk of bleeding. Speak with your doctor as the combination of anticoagulants and antibiotics may require a change in dose.
Avoid sun/tanning bed exposure while on antibiotics. Use sunscreen during daylight hours.
Potential side effects
Side effects are rare for ciprofloxacin (Cipro). However, it does share some similar potential side effects with metronidazole including:
Specific side effects
- Discolored urine (dark or reddish brown)
- Metallic taste in the mouth
Tingling in the hands and feet, particularly after long-term use, is a serious side effect. Even after the drug is discontinued,the tingling may persist. If you are experiencing tingling, tell your doctor immediately. You should not restart metronidazole if you experience this side effect.
Metronidazole affects the body’s ability to break down alcohol. Consuming alcohol with the medication may cause nausea and vomiting. Avoid alcohol until two days following the last medication dose.
Ciprofloxacin may interact with antacids (like Tums and Rolaids) vitamins, and minerals that contain calcium, iron, or zinc. Taking these vitamins/minerals with ciprofloxacin may reduce the effectiveness of the medication.
5. Biologic therapies (biologics)
Purpose: Varies by biologic. For IBD/Crohn’s disease, biologics used impact proteins that have to do with inflammation
Examples: Adalimumab (Humira), Certolizumab pegol (Cimzia), Golimumab (Simponi), Infliximab (Remicade), Natalizumab (Tysabri), Vedolizumab (Entyvio)
Biologics are an emerging branch of pharmacology offering new Crohn’s medications. As compared to other, chemical medications, biologics are synthesized from biological sources, living cells. Because of this difference in creation method, biologics can have incredibly targeted impact on the body.
We will look at two common types of biologics used to combat IBD/Crohn’s disease:
- Anti-tumor necrosis factor agents (anti-TNF)
- Integrin receptor antagonist
These biologics work by binding to a small protein called tumor necrosis factor alpha. Normally, this protein would promote inflammation in the intestines and other organs. The protein cannot perform this function when the biologic binds to it and blocks the function.
Not only does this reduce the symptoms of IBD, it also causes healing of the inflamed intestine.
Anti-TNF medications are not effective for everyone. It may take up to 8 weeks to start seeing improvement of symptoms.
Adalimumab (Humira), certolizumab pegol (Cimzia), golimumab (Simponi), and infliximab (Remicade) are injected biologics – delivered subcutaneously under the skin of the abdomen or thigh by the patient or a nurse. Each medication is administered on a particular schedule with doses decreasing in regularity as effectiveness is reached.
Integrin receptor antagonists
Biologics of this type keep white blood cells in the blood vessels and out of inflamed tissues. It toes this by blocking a protein on the surface of those cells.
Natalizumab (Tysabri) and vedolizumab (Entyvio) are examples of integrin receptor antagonists. These medications are delivered at certified infusion centers and each has a specific schedule.
Special consideration for Tysabri
There is a rare but serious risk of progressive multifocal leukoencephalopathy (a serious brain disease that can result in death or severe disability). This risk is a result of a potential John Cunningham (JC) virus infection.
It is important to be tested for JC before starting natalizumab.
Vedolizumab is used in similar situations as natalizumab, but it is gut-specific and does not enter the brain. Clinical trials on this medication do not associate it with progressive multifocal leukoencephalopathy.
Potential side effects
Biologics are given by intravenous infusions or subcutaneous injections. These may result in redness, itching, bruising, and/or pain at the injection. Additional side to biologic Crohn’s medications effects include:
- allergic reactions
- Biologics impact the immune system and may inhibit your ability to fight infection
- Patients should stay up to date on vaccinations and be aware of chronic, asymptomatic infections including tuberculosis (TB) and Hepatitis B
- Cancer Risk
- Anti-TNF medications are associated with small increase in lymphoma incidence
- Liver damage
- Monitor your skin for jaundice (yellowing of skin and eyes) and alert your doctor if you notice indications
- Lupus-like sypmtoms
- Check for lupus symptoms – may notice rash, joint pain, muscle ache, etc.
- Joint pain and inflamed joints should be discussed with your doctor
As with all Crohn’s medications, speak with your doctor about any concerns you have. It is important to work with your provider to determine appropriate dosing and Crohn’s medications schedules