Treatment for IBD may include medical management
, surgical interventions
, complementary/alternative medicine
(CAM) or lifestyle changes (such as quitting smoking). It is important to talk about any treatments or changes to treatment with the gastroenterologist.
Several types of medicines are often used to manage IBD, including aminosalicylates, steroids, immunosuppressants and biologics.
are anti-inflammatory medications used to help control or reduce inflammation in the digestive tract. They work directly on the lining of the bowel, especially in those who have just been diagnosed or those with mild symptoms. Mesalamine, also known as 5-aminosalicylic acid (5-ASA), is the active component believed to deliver the anti-inflammatory effects via oral (by mouth) or rectal (by rectum) delivery.
- Sulfasalazine (brand name: Azulfidine®)
- Mesalamine (brand names: Asacol®, Pentasa®, Apriso®, Lialda®, Delzicol®)
- Balsalazide (brand names: Giazo®, Colazal®)
- Olsalazine (brand name: Dipentum®)
Sulfasalazine, balsalazide and olsalazine are oral medications that work in different ways to lessen inflammation in the large intestine (colon and rectum). Mesalamine is available in many oral and rectal forms, each of which targets different parts of the digestive tract. The most common side effects with 5-ASAs include headache, diarrhea, bloating and nausea.1
Patients taking 5-ASAs should be seen regularly by a health care team to check for side effects.
, or steroids, are strong anti-inflammatory agents used to treat moderate to severe relapses of IBD. They act by slowing down multiple inflammatory pathways. Corticosteroids are available in oral, rectal and intravenous (medicine given directly into a vein) forms. When people take corticosteroids, their adrenal glands slow down or stop making cortisol, a hormone naturally made by the body’s adrenal glands.
For people with moderate to severe active IBD, corticosteroids include:
- Prednisone (brand name: Deltasone®)
- Methylprednisolone (brand name: Medrol®)
- Hydrocortisone (brand name: Cortef®, Cortril®, Hydrocortone®)
- Budesonide (brand names: Entocort® EC, Uceris™)
Budesonide is part of a new class of corticosteroids called nonsystemic steroids because they target the intestine rather than the whole body. By doing so, they cause fewer side effects. Budesonide capsules are designed to slow the release of budesonide until the drug reaches the ileum and ascending colon.2
The side effects of corticosteroids are affected by the dose and length of treatment. They are only recommended for short-term use to reach remission, because they are not effective at preventing flare-ups. Long-term or frequent use of these steroids is not recommended because of their undesirable side effects.
New formulations of glucocorticosteroids have been introduced with the goal of the same effectiveness of steroids already available but with fewer side effects.
Some common side effects of corticosteroids include:
- Increased appetite and weight gain.
- Face puffiness.
- Increased facial hair.
- Night sweats.
- Trouble sleeping.
- Mood changes.
Some longer-term (i.e., when steroids are taken for more than six to 12 months) side effects include diabetes mellitus (poor control of sugar) and osteoporosis (thinning of the bones).
are medicines that decrease the normal immune system response. These drugs are used to control severe symptoms or when a patient cannot stop taking steroids. They are also used in combination with biologics (see below). They are safe, but liver function and white blood cell counts need to be regularly checked.
- Oral medicines
- Azathioprine (brand name: Azasan®, Imuran®)
- 6-Mercaptopurine (6-MP; brand name: Purinethol®, Purixan®)
- Tofacitinib (brand name: Xeljanz®)
- This is an oral medication approved for moderate to severe UC that works by inhibiting the Janus kinase (JAK) protein family, which consists of JAK 1, 2 and 3 and the related kinase tyrosine kinase 2.
- Methotrexate (brand name: Abitrexate®, Folex®, Mexate®)
- This drug can cause miscarriage and must not be taken during pregnancy because it can cause deformities in the fetus.
Possible side effects include:
- Nausea or vomiting.
- Diarrhea (loose stool).
- Decreased ability to fight infections (because of a low white blood cell count).
- Fatigue or feeling tired.
are complex proteins designed to bind or block specific targets. Biologics are made partly or completely from living biologic sources, such as animals and humans. They have active ingredients, such as antibodies or hormones, and include a broad range of drugs, differing in how they work and how they are given.
What are biologic and biosimilar drugs?
A biosimilar is a biologic based on an existing (originator) biologic but is not an exact copy. Biosimilars work the same way as their originator biologics and are given the same way.
Many types of biologics are available to treat IBD. These biologics are given either orally, by injection (a shot under the skin) or infusion into a vein.
- Tumor necrosis factor (TNF) antagonists bind and block a small protein called TNF-α, which is linked to swelling in the intestine and other organs and tissues. TNF antagonists lessen the symptoms of IBD and help healing of an inflamed intestine. Examples include:
- Adalimumab (brand name: Humira®)
- Certolizumab brand name: (Cimzia®)
- Infliximab (brand name: Remicade®)
- Infliximab-abda (brand name: Renflexis), Remicade biosimilar
- Infliximab-dyyb (brand name: Inflectra), Remicade biosimilar
- Golimumab (brand name: Simponi®)
- Integrin receptor antagonists block a protein on the surface of cells and prevents them from moving out of the blood vessels and into tissues. An example is:
- Vedolizumab (brand name: Entyvio®)
- Interleukin (IL) 12 and IL-23 antagonists block two cytokines (chemicals made by cells that affect other cells, specifically IL-12 and IL-23) from causing swelling in Crohn’s disease and ulcerative colitis. An example is:
- Ustekinumab (brand name: Stelara®)
Every medication balances how well it works with potential side effects. Some therapies increase the risks of infections and some may increase the risk of other autoimmune conditions. Others work more selectively on the intestines and have less risks. Each treatment is different, so it is very important to talk with the health care team about specific risks and benefits of the treatment options.
Before prescribing a biologic, the gastroenterologist will:
- Look at the medical history.
- Do a physical examination.
- Immunize against vaccine-preventable diseases, including hepatitis A and B viruses, shingles, influenza (annually), human papillomavirus, and pneumonia.
- Test for tuberculosis.
Routine follow-up care during treatment with blood tests and physical exam also helps to ensure safety.
When prescribing biologics, the health care team will also think about how well the drug will work, how it is administered, the patient’s preferences and the cost of the medication.
1. Karagozian R, Burakoff R. The role of mesalamine in the treatment of ulcerative colitis. Ther Clin Risk Manag. 2007;3(5):893-903.
2. Katz S. The practical use of corticosteroids in the treatment of inflammatory bowel disease. Pract Gastroenterol. 2005;29:1-25. https://www.practicalgastro.com/pdf/January05/Jan05Katz.pdf. Accessed April 8, 2019.
3. Hwang JM, Varma MG. Surgery for inflammatory bowel disease. World J Gastroenterol. 2008;14(17):2678-2690.
4. Cheifetz, Gianotti R, Luber R, Gibson PR. Complementary and alternative medicines used by patients with inflammatory bowel diseases. Gastroenterology. 2017;152(2):415-429.
Supported by an educational grant from Takeda Pharmaceuticals U.S.A., Inc.