Medication Options for Treating IBD

Aminosalicylates (also known as 5-ASA) are medicines that contain 5-aminosalicylic acid and reduce inflammation in the lining of the intestines. While aminosalicylates can be used in both diseases, they are primarily used to induce and maintain remission in mild to moderate ulcerative colitis.

Other important points to know about this class of medication:

• Depending on the specific medication, they can be taken orally or rectally (with enemas or suppositories).
• They are often well-tolerated and safe and are not linked to increased risk of infections or cancer.
• Common types include sulfasalazine and mesalamine.
  • Patients with a sulfa allergy should not take sulfasalazine. Additionally, a decrease in sperm production and function in men can occur while taking sulfasalazine. However, sperm count becomes normal after the medication is discontinued.
• These medications can sometimes cause side effects like headaches or stomach pain.
• Aminosalicylates very rarely cause kidney injury. However, those with known kidney problems should carefully discuss aminosalicylate use with their doctor and kidney tests should be performed routinely.

Full list of FDA approved aminosalicylates commonly prescribed for IBD

Corticosteroids (often referred to simply as steroids) are powerful and fast-acting anti-inflammatory medications that reduce inflammation in both the intestine and throughout the body, including the joints, skin, and eyes. They are best suited for short-term control of IBD symptoms and disease activity and should NOT be used as a primary therapy for long periods of time.

Other important points to know about this class of medication:

• Depending on the specific medication, they can be taken orally or rectally (with enemas, suppositories, or rectal foams).
• Common types include prednisone, budesonide, and methylprednisone.
• Corticosteroids exert their anti-inflammatory effect by suppressing immune system activity. As a result, they can leave individuals more susceptible to infections. They also can result in additional serious side effects depending upon the dose and duration which may include:
  • High blood pressure
  • High blood sugar levels
  • Weakened bones
  • Cataracts
  • Weight gain
  • Acne
  • Rounding of the face (“moon face”)
  • Increased facial hair
  • Difficulty sleeping
  • Mood swings
  • Growth disturbance in children

Due to the risks and side effects, when corticosteroids are used, doctors will try to minimize the length of time and dosage by tapering the medication (decreasing the does gradually over time) when it is appropriate.

Full list of FDA approved corticosteroids commonly prescribed for IBD

Immunomodulators are medicines that change how the immune system works in order to reduce inflammation in the body. A doctor may use immunomodulators when other medicines don’t work well in managing your Crohn’s disease or ulcerative colitis.

Other important points to know about this class of medication:

• Immunomodulators can be taken alone or in combination with other medications to make them more effective
• They can be taken orally, injected or applied as creams (for skin problems)
• Common immunomodulators taken for IBD include azathioprine, 6-MP, cyclosporine, tacrolimus, and methotrexate
• It can take 3-6 months for immunomodulators to start working. Your doctor may give you another fast-acting medication at the same time (i.e. a steroid or in combination with a biologic)
• Patients taking immunomodulators should be regularly vaccinated for flu, pneumonia, and shingles
   

Full list of FDA approved immunomodulators commonly prescribed for IBD

Antibiotics can be used in the management of IBD, including Crohn’s disease and ulcerative colitis. They are used to treat infections that may occur as a result of the disease itself, or from suppression of immunity. Sometimes infections can look a lot like the symptoms of an IBD flare. Your doctor will check to see if an infection may be the cause of the change in your symptoms.

Common reasons for taking an antibiotic for IBD include:

• Clostridioides difficile (C. diff) colitis – a bacteria called C. diff that attacks the intestines (usually the colon) and can cause fever, abdominal pain, cramping, diarrhea, and bloody stools.
• Giardia lamblia as well as some other parasites and bacteria that can cause infections.
• To manage inflammation or complications of IBD.
• To treat abscesses or fistulas that may develop in individuals with Crohn’s disease.
• To prevent recurrence of Crohn’s disease soon after surgery.
• To treat pouchitis following surgery to remove the colon and creation of a pouch.

Other important points to know about this class of medication:

• Antibiotics are taken orally or through an IV.
• Antibiotics are generally well tolerated but may commonly cause side effects including nausea, loss of appetite, rash, diarrhea, dizziness and headaches.
• Despite treating infections, antibiotics themselves may make you more susceptible to new infections, especially C. diff. Your healthcare team may recommend the use of a probiotic to try and replenish helpful gut bacteria which prevents development of other infections.

Some of the more commonly prescribed antibiotics will include:

• Ciprofloxacin
• Metronidazole
• Augmentin
• Rifaximin

Full list of FDA approved antibiotics commonly prescribed for IBD

Biologics are antibodies, created in the laboratory, that target specific proteins that cause the inflammation that occurs in IBD. There are a number of biologic medications that are available for Crohn’s disease and ulcerative colitis and your doctor will recommend different options and work with you as you begin or change your treatment plan. Although biologics, like any other medications, are not a cure for IBD, they can help control your symptoms, reduce inflammation, and help you and your doctor work towards a goal on achieving remission.

Biosimilars are biologic medications that are nearly identical copies of already approved biologic medications. There are no meaningful differences between the biosimilar and its matching biologic medication. They are just as safe and effective and are taken in the same form and dose. Most of the time, insurance companies may offer a biosimilar instead of its original biologic simply to cut cost, without having any meaningful change in the effectiveness of the medication.

Learn more about biosimilars

Types of Biologic Therapies

Anti-Tumor Necrosis Factor Agents (Anti-TNF)

Anti-TNF medications are a type of biologic medication that stops a small protein in your body (known as tumor necrosis factor or TNF) from causing inflammation. It may take up to 8–12 weeks after starting this medication to notice an improvement in symptoms.

• Anti-TNFs are indicated for patients with Crohn’s disease and ulcerative colitis.
• These medications can be given as injections or intravenous infusions.
• There are Anti-TNF biosimilar medications available.

Integrin Receptor Antagonists

These biologics prevent inflammation from occurring in the body, but they target different proteins called integrin receptors.

• They are indicated for patients with Crohn’s disease and ulcerative colitis.
• These medications are administered by intravenous infusions and can be followed by infusions or injections for maintenance therapy.

Interleukin Antagonists

These biologics target specific proteins (interleukins) that play a key role in inflammation.

• They are indicated for patients with Crohn’s disease and ulcerative colitis.
• Some of these medications are given as first doses by intravenous infusion followed by injections while others are only given as injections without any need for infusions.
• There are interleukin antagonist biosimilar medications available.

Common Side Effects

• You may have redness, itching or pain at the site where you place the injection or infusion.
• Common side effects of biologic medications include headache, fatigue, fever, chills, hives and rashes.
• In rare cases, people may have allergic reactions

Infections

• Biologics affect the immune system and may impact your ability to fight infections.
• While taking this medication, talk to your doctor about ways to prevent infections such as being up-to-date on appropriate vaccinations including influenza, pneumonia, shingles, hepatitis A & B, and others.
• If you develop a fever or any other signs suggestive of an infection like a pneumonia, UTI, etc; be sure to tell your doctor right away.

Rare Risks

• Anti-TNF medications taken along with other immune suppressing medications have been associated with a small increase in lymphoma, a type of a blood cancer.
• Liver problems
• Joint pains
• Lupus-like reactions
• Skin reactions including slightly increased risk of developing non-melanoma type skin cancers

Combination Therapy

In some circumstances, your doctor may recommend adding an additional therapy to work in combination with the initial therapy. For example, this could include the addition of an immunomodulator (another type of immunity suppressing medication) to a biologic. Combining therapies can increase the effectiveness of the biologic, but there may also be an increased risk of additional side effects. Your doctor will work with you to identify the treatment option that is most effective for your individual needs.

Full list of FDA approved biologics commonly prescribed for IBD

Targeted synthetic small molecules are medicines that help reduce inflammation by specifically targeting parts of the immune system that play a role in inflammation in the intestine and other organs. There are two types of small molecules currently available to treat IBD: JAK Inhibitors and S1P Receptor modulators.

JAK Inhibitors

• Taken orally and directly absorbed into the bloodstream through the intestines
• They block the activity of one or more JAK enzymes found in cells and regulate the overactive immune system
• Tofacitinib and Upadacitinib are FDA-approved for adults with moderate-to-severe Crohn’s disease and ulcerative colitis
• Common side effects include upper respiratory tract infections, headache, fatigue, acne and a higher risk for developing shingles

 S1P (sphingosine 1-phosphate) Receptor Modulators

• Taken orally and directly absorbed into the bloodstream through the intestines
• They work by preventing the migration of immune cells from the lymph nodes to the intestines where they cause inflammation in ulcerative colitis
• Ozanimod and etrasimod are FDA-approved for adults with moderate-to-severe ulcerative colitis.
• Common side effects include infections, elevated liver enzymes, headache, and dizziness.
• Do not take ozanimod or etrasimod if in the last 6 months you experienced myocardial infarction, unstable angina pectoris, stroke, transient ischemic attack, decompensated heart failure requiring hospitalization, or Class III or IV heart failure or have or have had a history of unusual heartbeats (arrhythmia) that is not corrected by a pacemaker.

Other important points to know about this class of medication:

• While on one of these medications, it is important to be vaccinated against infections that are preventable. You must, however, avoid live vaccines while you are on one of these agents

Prior to starting these medications, your healthcare team will request blood work. Blood work that will be collected may include blood counts to look for anemia or a low white blood cell count, chronic infections, such as tuberculosis (TB) and hepatitis B, liver and kidney function tests, and cholesterol levels.

Full list of FDA approved targeted synthetic small molecules commonly prescribed for IBD