Medical treatment for Crohn’s disease and ulcerative colitis has two main goals: achieving remission (control or resolution of inflammation leading to symptom resolution) and then maintaining remission.
Over the last several years, new treatments called biologics have been available for the treatment of inflammatory bowel disease (IBD) and other inflammatory diseases. These treatments are called biologics because, unlike chemical medications, they are made out of materials found in life.
Biologics are antibodies grown in the laboratory that stop certain proteins in the body from causing inflammation. Biologic therapies offer a distinct advantage in IBD treatment because their mechanisms of action are more precisely targeted to the factors responsible for IBD. For example, unlike corticosteroids, which affect the whole body and may produce major side effects, biologic agents act more selectively. These therapies are targeted to particular proteins that have already been proven to be involved in people with IBD.
ANTI-TUMOR NECROSIS FACTOR AGENTS
Biologics known as anti-tumor necrosis factor (anti-TNF) agents bind and block a small protein called tumor necrosis factor alpha (TNF-alpha) that promotes inflammation in the intestine as well as other organs and tissues. All anti-TNF medications have been shown to not only reduce the symptoms of IBD, but also result in healing of inflamed intestine. While anti-TNF medications are not effective for every individual, many patients benefit from this class of medication. It may take up to 8 weeks after starting an anti-TNF to notice an improvement in symptoms, though many experience more immediate improvement. Examples of anti-TNF medications include:
- Adalimumab (Humira®) is a prescription medicine shown to induce and maintain clinical remission in patients with moderate to severe Crohn’s disease and ulcerative colitis. Adalimumab is given as a subcutaneous injection under the skin of the abdomen or thigh. Once instructed by a healthcare professional, the patient or family member can administer it at home. The injection process takes about 10 seconds. Typically, when starting adalimumab patients will perform four injections for their first dose (4 pens, 160mg), then two weeks later they will perform two injections (2 pens, 80mg). Thereafter, patients will perform one injection (1 pen, 40mg) every two weeks.
- Certolizumab pegol (Cimzia®) is another self injected anti-TNF used to reduce the signs and symptoms, as well as maintain clinical response, of moderate to severe Crohn’s disease. Patients treated with certolizumab pegol usually receive an injection every two weeks for the first three injections. Once benefit has been established, it is usually given once every four weeks. Depending on the physician’s orders, it is injected under the skin by either a healthcare professional (typically a nurse) or the patient.
- Golimumab (Simponi®) is indicated for the treatment of adult patients with moderate to severe ulcerative colitis who are unable to wean off steroids or who have had an inadequate response to, or intolerance to, other ulcerative colitis medications. Golimumab is usually injected every four weeks after two starter doses. Once instructed by a healthcare professional, the patient or family member can administer it at home.
- Infliximab (Remicade®) has been approved for the treatment and maintenance of remission of moderate to severe Crohn’s disease and ulcerative colitis (in adults and children). It is also approved for reducing the number of draining enterocutaneous and rectovaginal fistulas and maintaining fistula closure in adult patients with fistulizing disease. It is given by an intravenous infusion lasting approximately two to four hours. The first three doses are given more closely together, at zero, two, and six weeks, and thereafter usually every six to eight weeks.
- Infliximab-dyyb (Inflectra®) is biosimilar to infliximab (Remicade®). It has been approved for the treatment of adult and pediatric patients with moderately to severely active Crohn’s disease, as well as adults with moderately to severely active ulcerative colitis, who have had an inadequate response to conventional therapy. It is given by intravenous infusion (lasting approximately two to four hours) at zero, two, and six weeks, then every eight weeks thereafter.
INTEGRIN RECEPTOR ANTAGONISTS
These biologics prevent the cells that cause inflammation from moving out of blood vessels and into tissues by blocking a protein on the surface of those cells. Examples of this type of medication include:
- Natalizumab (Tysabri®) has been approved for inducing and maintaining clinical response and remission in adult patients with moderate to severe Crohn’s disease who have had an inadequate response to, or are unable to tolerate, other forms of therapy. It is infused into a vein at a certified infusion center and is usually given once every four weeks. It takes about one hour to receive the entire dose. Natalizumab works throughout the entire body. Natalizumab users carry an increased risk of a severe brain condition called progressive multifocal leukoencephalopathy (PML), resulting from infection with the John Cunningham (JC) virus. It is important to be tested for JC virus prior to starting natalizumab; patients who are negative for JC virus have a much lower risk of developing PML.
- Vedolizumab (Entyvio™) has been approved for inducing and maintaining clinical response and remission and achieving steroid-free remission in adult patients with moderate to severe Crohn’s disease and ulcerative colitis who have had an inadequate response with, lost response to, or were intolerant to an anti-TNF or immunodmodulator; or had an inadequate response with, were intolerant to, or demonstrated dependence on corticosteroids. Vedolizumab works through a mechanism similar to natalizumab but is gut-specific and has not been shown to enter the brain. In large clinical trials, it was not associated with the brain disorder progressive multifocal leukoencephalopathy (PML) that is rarely observed in those using natalizumab (Tysabri). This drug is infused intravenously over approximately 30 minutes at zero, two and six weeks, then every eight weeks thereafter.
RISKS & SPECIAL CONSIDERATIONS
While the benefits often far outweigh the risks of biologic medications in patients suffering from IBD, patients should consider the following when using biologics:
- Side Effects & Intolerance. Because biologics are given by intravenous infusions or subcutaneous injections, they may produce redness, itching, bruising, pain, or swelling at the injection site. Other side effects may include: headache, fever, chills, hives and other rashes. Occasional severe allergic reactions may occur.
- Infections. Because biologics affect the immune system to help control IBD, biologics can impact your ability to fight infections. Further, anti-TNF medications increase the risk of developing less common, or atypical, infections. While the majority of patients using biologics never experience an infection related to the medication, it is important to discuss this issue with your IBD specialist. Because of this risk, it is important to determine if a patient has any chronic asymptomatic infections that may become reactivated when using these medications, including tuberculosis (TB) and chronic Hepatitis B virus. Further, to help prevent infections, patients should be up-to-date on appropriate vaccinations, including yearly influenza vaccinations. If you develop any signs of infection while taking these medications, such as fever, new cough, or the flu, inform your doctor immediately.
- Cancer Risk. Anti-TNF medications have been associated with a small, but measurable, increase in the incidence of lymphoma, an uncommon cancer. While the overall risk of lymphoma is very low, the risk is highest in patients using anti-TNF medications in combination with another immunosuppressant, such as azathioprine (Imuran®).
- Liver Problems. Biologic therapies have been rarely associated with changes in liver function. If you develop jaundice (yellowing of skin and eyes) while using biologics, inform your doctor immediately.
- Arthritis. While anti-TNF medications often are effective treatments for inflammatory arthritis (joint pain), in some situations they may cause new joint pain. Notify your doctor if you are experiencing new joint discomfort while using anti-TNF medications.
- Lupus-like Reaction. Rarely an anti-TNF medication can cause a lupus-like reaction (LLR) which may present with symptoms such as a rash, joint pain, muscle ache, and/or fever. The LLR usually resolves with stopping the anti-TNF, but may require a course of corticosteroids.
- Other Considerations. Tell your doctor if you have any other health problems such as heart failure, hepatitis or multiple sclerosis before taking these treatments. Your doctor will determine if the benefits of biologics outweigh the risks in your individual situation.
On rare occasions, nervous system disorders also have been reported. Let your doctor know if you have or have had a disease that affects the nervous system, or if you experience any numbness, weakness, tingling, or visual disturbances while using anti-TNF medications.
In some circumstances, a health care provider may recommend adding an additional therapy that will work in combination with the intial therapy to increase its effectiveness. For example, combination therapy could include the addition of an immunomodulator to a biologic. As with all therapy, there are risks and benefits of combination therapy. Combining therapies can increase the effectiveness of IBD treatment, but there may also be an increased risk of additional side effects and toxicity. Your healthcare provider will identify the treatment option that is most effective for your individual health care needs.
TAKE MEDICATIONS AS PRESCRIBED
The best way to control IBD is by taking medications as recommended by your doctor. Even during times of remission, it is important to continue taking your medications as prescribed to prevent asymptomatic inflammation and future flares. If you are experiencing unpleasant side effects or you continue to have IBD symptoms, do not stop taking your medications until speaking with your doctor. Do not alter the amount of medication or how frequently you take it on your own.
Watch this webcast to learn more about biologic therapies in IBD.
For further information, call Crohn's & Colitis Foundation's IBD Help Center: 888.MY.GUT.PAIN (888.694.8872).
The Crohn's & Colitis Foundation provides information for educational purposes only. We encourage you to review this educational material with your health care professional. The Foundation does not provide medical or other health care opinions or services. The inclusion of another organization's resources or referral to another organization does not represent an endorsement of a particular individual, group, company or product.
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Published: February 6, 2014