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Drugs that affect the underlying inflammation of IBD are used to:
- suppress inflammation in patients with active disease
- prevent flare-ups in those with inactive disease
The five types of medication in this group are presented in alphabetical order — which may not be the order in which they will be used. For example, biological therapies are generally used last, after combinations of other drugs have been tried but found not to produce satisfactory results.
The active ingredient in these medications is 5-aminosalicylic acid or 5-aminosalicylate (5-ASA), which blocks the production of potent inflammatory factors called prostaglandins.
5-ASA is mainly used as long-term maintenance therapy for patients with inactive Crohn’s or colitis, to reduce the chance of a flare-up. 5-ASA is also helpful for the treatment of mild attacks of Crohn’s or colitis.
Drugs that contain 5-ASA are special formulations that deliver 5-ASA to parts of the intestine affected by IBD. Unless specially formulated, 5-ASA taken by mouth is absorbed in the upper part of the gut and is thus not effective in most cases of IBD. Depending upon the formulation, the 5-ASA is released into the lower part of the small bowel or into the large bowel. Available products include:
- sulfasalazine (Salazopyrin® and S.A.S.®), which you should not use if you have an allergy to “sulfa” antibiotics (such as Bactrim®, Septra®, and others).
- mesalazine, the active ingredient in formulations called Asacol®, Pentasa®, Mesasal®, and Salofalk®
- olsalazine (Dipentum®), which is active in the colon
Although all the 5-ASA medications are similar, individual patients may respond better to specific products.
In some instances, 5-ASA or sulfasalazine may be given by enema to help control attacks of ulcerative colitis in the lower colon.
5-ASA is often used on a chronic (long-term) basis.
Certain antibiotics are helpful in certain cases, even though it is not clear how they work. The two most commonly used antibiotics are metronidazole (Flagyl®) and ciprofloxacin (Cipro®). Both may be given by mouth, in the lowest amount that is effective.
Drinking alcohol while taking metronidazole can make you feel very, very sick.
These medications regulate the balance between molecules that cause inflammation, and others that reduce inflammation.
The most commonly-used medication in this group is infliximab (Remicade®). Infliximab is given by intravenous infusion. Each infusion takes about 2 hours to administer, and doses are generally given every 8 weeks.
A newer alternative, adalimumab (Humira®), is given by subcutaneous injection instead of infusion.
Medications in this group are also referred to as “corticosteroids” or “steroids.” Glucocorticosteroids block the action of several types of inflammatory molecules. Their effects are very different from those of the “anabolic” or male steroids that some athletes and bodybuilders misuse.
Members of this group include budenoside (Entocort®), prednisone, and prednisolone. They may be given by the oral, intravenous, or rectal routes, according to the patient’s condition.
Entocort® is formulated to release the active agent into the lower small intestine and upper colon. Other oral preparations are absorbed higher in the intestine, and have more systemic effects and side-effects.
These medications are often used when 5-ASA products don’t provide enough symptom control, when symptom severity becomes moderate-to-severe, or during acute flare-ups. They are the most effective medications for treating moderate to severe IBD.
Steroids are generally used for short courses, and treatment must be discontinued gradually, to minimize side-effects.
The medications in this group are also referred to as “immunomodulators,” and each has a unique action. Immunomodulators include:
- azathioprine (Imuran®) and mercaptopurine (6-MP; Purinethol®)
- cyclosporine (Neoral®)
Because the body converts azathioprine to 6-MP, azathioprine and 6-MP have similar actions. They reduce the activity of the immune system, may be combined with other medications such as 5-ASA and prednisone, and may reduce the need for steroids. Either drug may be helpful for Crohn’s or colitis patients who are not responding adequately to steroids, or who have frequent flare-ups. Several months of use may be needed for the full effect to develop. Azathioprine and 6-MP are taken as oral tablets.
Cyclosporine is considered a “rescue” treatment, used when other treatments haven’t helped severe ulcerative colitis. It is usually started in hospital, by intravenous infusion, and can be continued as oral capsules or liquid when you are discharged.
Methotrexate also is generally used for IBD that is not responding to other drugs. It is given weekly, as a tablet or injection.