Inflammatory Bowel Disease - Medications

What medications have been effective in treating IBD?

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Inflammatory Bowel Disease Medications

Different groups of drugs are used for the treatment of persons with inflammatory bowel disease. These include aminosalicylates, corticosteroids, immune modifiers, anti-tumor necrosis factor (TNF) agents, and antibiotics.

Aminosalicylates

  • Amino salicylates are aspirin like anti-inflammatory drugs. The oral 5 amino salicylate preparations available for use in the US: sulfasalazine (Azulfidine), mesalamine (Asacol, Pentasa, Apriso, Lialda), olsalazine (Dipentum), balsalazide (Colazal) . The topical rectal formulation of mesalamine is Rowasa and Canasa.
  • These drugs can be given either orally or rectally (enema, suppository formulations). They are useful both for treating flare-ups of the IBD and the maintenance of remission.

Corticosteroids

  • Corticosteroids are rapid-acting anti-inflammatory agents. The indication for use in IBD is for acute flare-ups of the disease only. There is no role for corticosteroids in the maintenance of remission.
  • Corticosteroids may be administered by a variety of routes, depending upon the location and severity of disease; they may be administered intravenously (methylprednisolone [Medrol, Medrol Dosepak], hydrocortisone [Cortef, Hydrocortone]) in the hospital, orally (prednisone, prednisolone, budesonide [Entocort EC), dexamethasone [AK-Dex, Ocu-Dex]), or rectally (enema, suppository, foam preparations).
  • Corticosteroids tend to provide rapid relief of symptoms as well as a significant decrease in inflammation, but their side effects limit their use (particularly longer-term use). The consensus for treatment with corticosteroids is that they should be tapered as soon as possible.

Immune Modifiers

  • Immune modifiers include 6-mercaptopurine (6-MP, Purinethol) and azathioprine (Imuran). Immune modifiers may work by causing a reduction in the lymphocyte count (a type of white blood cell). Their onset of action is relatively slow (typically 2 to 3 months).
  • They are used in selected persons with IBD when aminosalicylates and corticosteroids are either ineffective or only partially effective. They are useful in reducing or eliminating some persons' dependence on corticosteroids.
  • Immune modifiers may also be helpful in maintaining remission in some persons with refractory ulcerative colitis (persons who do not respond to standard medications).
  • They are also used as primary treatment of fistulae and the maintenance of remission in persons who cannot tolerate amino salicylates.
  • If a patient is taking immune modifiers, their blood cell count will be monitored on a regular basis because the immune modifiers can cause a significant reduction in the number of white blood cells, predisposing the patient to serious infections.
  • It is advisable to take folic acid as a supplement when taking immune modifiers.

Anti-TNF Agents

Examples of anti-TNF agents include infliximab (Remicade), adalimumab (Humira), and certolizumab (Cimzia).

  • Infliximab (Remicade) is an anti-TNF agent. TNF is produced by white blood cells and is believed to be responsible for promoting the tissue damage noted in persons with Crohn's disease. Infliximab acts by binding to TNF, thereby inhibiting its effects on the tissues.
  • It is approved by the FDA for the treatment of persons with moderate-to-severe Crohn's disease who have had an inadequate response to standard medications. In such persons, a response rate of 80% and a remission rate of 50% have been reported.
  • Infliximab is also used for the treatment of fistulae, a complication of Crohn's disease. Closure of fistulae has been reported in 68% of persons treated with infliximab.
  • Infliximab must be given intravenously. It is very expensive, so insurance coverage may play a factor in the decision to use this drug.

Antibiotics

  • Metronidazole (Flagyl, Flagyl 375, Flagyl ER) and ciprofloxacin (Cipro, Cipro XR, Proquin XR) are the most commonly used antibiotics in persons with IBD.
  • Antibiotics are used sparingly in persons with ulcerative colitis because they have an increased risk of developing antibiotic-associated pseudomembranous colitis (a type of infectious diarrhea).
  • In persons with Crohn's disease, antibiotics are used for the treatment of complications (perianal disease, fistulae, inflammatory mass).
  • It is generally recommended that the use of metronidazole and ciprofloxacin be limited to short durations and be used intermittently as much as possible. Long term continuous use of metronidazole can lead to peripheral neuropathy - tingling and numbness in feet. Ciprofloxacin in long term continuous use can cause rupture of the Achilles tendon.
Symptomatic treatments: Patients may be given antidiarrheal agents, antispasmodics, and acid suppressants for symptomatic relief.

Experimental Agents

  • Drugs used in Crohn's disease include methotrexate, thalidomide (Thalomid), and interleukin-11.
  • Drugs used in ulcerative colitis include cyclosporin A, nicotine patch, butyrate enema, and heparin.
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