Aminosalicylates contain the compound 5-aminosalicylic acid, or 5-ASA, which helps reduce inflammation. These drugs are sometimes used to prevent relapses and maintain remission in mild-to-moderate Crohn disease. They are used more often to treat ulcerative colitis than Crohn disease.
5-ASA Types: The standard aminosalicylate drug is sulfasalazine (Azulfidine, generic). This drug combines the 5-ASA drug mesalamine with sulfapyridine, a sulfa antibiotic. The sulfa component of the drug can cause unpleasant side effects, including headache, nausea, and rash.
People who cannot tolerate sulfasalazine, or who are allergic to sulfa drugs, have other options for aminosalicylate drugs, including:
- Mesalamine (Asacol, Pentasa, generic)
- Olsalazine (Dipentum)
- Balsalazide (Colazal, generic)
These drugs, like sulfasalazine, are available as pills. Mesalamine is also available in enema (Rowasa, generic) and suppository (Canasa) forms.
Side Effects of 5-ASAs: Common side effects of aminosalicylate drugs may include abdominal pain and cramps, diarrhea, gas, headaches, and nausea
Corticosteroids (commonly called steroids) are powerful anti-inflammatory drugs used to treat moderate-to-severe Crohn disease. Because long-term steroid use can cause significant side effects, corticosteroids are used only a short period of time with the goal of inducing remission. Corticosteroids do not prevent flare-ups and are not used for maintenance treatment.
Corticosteroid Types: Prednisone (Deltasone, generic) is the main corticosteroid used for treating Crohn disease. Budesonide (Entocort, Uceris) is a newer type of steroid that is used as an alternative. Prednisone is a systemic steroid, which circulates throughout the body. Budesonide affects only local areas in the intestine so it tends to cause fewer widespread side effects. The choice of which steroid to use depends in part on where in the colon the disease is located.
Prednisone and budesonide are administered as pills, and are sometimes used in combination with the immunosuppressant azathioprine. In very severe cases of Crohn disease, other types of steroids may be used in intravenous or rectal formulations.
Side Effects of Corticosteroids: Common side effects of short-term treatment with oral steroids can include acne, increased appetite, and insomnia. Long-term treatment with steroids increases the risk for many serious side effects including low bone density (osteoporosis), high blood pressure, and cataracts.
Withdrawing from Corticosteroids: Once remission is achieved and the intestinal inflammation has subsided, steroids must be withdrawn very gradually. Withdrawal symptoms, including fever, malaise, and joint pain, may occur if the dosage is lowered too rapidly. If this happens, the dosage is increased slightly and maintained until symptoms are gone. More gradual withdrawal is then resumed. To maintain remission, people who are treated with steroids are given an immunomodulator drug (azathioprine, mercatopurine, or methotrexate) or an anti-TNF drug (infliximab or adalimumab).
Some people cannot stop taking steroids without having a relapse of their symptoms. They may be treated with immunomodulators or biologic drugs, or be candidates for surgery.
Immunosuppressive Drugs (Immunomodulators)
Immunosuppressant drugs, also called immunodulators, suppress or limit actions of the immune system and therefore the inflammatory response that causes Crohn disease. These drugs may be used in combination with an anti-TNF drug to induce remission. They may also be used alone to maintain remission in people who were treated with steroid drugs.
Immunosuppressants allow corticosteroids to be withdrawn while keeping the disease under control. For this reason, immunosuppressants are sometimes referred to as steroid-sparing drugs.
Immunomodulator Types: Azathioprine (Imuran, Azasan, generic) and mercaptopurine (6-MP, Purinethol, generic) are the standard oral immunosuppressant drugs. They belong to a class of medications called thiopurines.
Methotrexate [(MTX), Rheumatrex, generic] is another type of immunosuppressant. It is given as a weekly injection.
Side Effects of Immunomodulators: General side effects of immunosuppressants may include nausea, vomiting, susceptibility to infections, and liver or pancreatic inflammation. People who take these drugs should receive frequent blood tests to monitor white blood cell count and liver function.
A serious concern associated with thiopurines is increased risk for lymphoma, a cancer that starts in the immune system. Methotrexate can cause miscarriages and birth defects. Both men and women who take methotrexate should use birth control.
Biologic drugs are genetically engineered to target specific proteins involved with the body's inflammatory response.
Biologic Drug Types: Tumor necrosis factor (TNF) blockers, commonly called anti-TNFs, are the main biologic drugs used for treating Crohn disease. The three anti-TNF drugs approved for Crohn disease are infliximab (Remicade), adalimumab (Humira), and certolizumab (Cimzia).
Other types of biologic drugs approved for Crohn disease are natalizumab (Tysabri) and vedolizumab (Entyvio). These drugs are similar to each other and work in a different way than anti-TNF drugs.
The American Gastroenterological Association recommends an anti-TNF drug as a first-line treatment for inducing and maintaining remission in people with moderate-to-severe Crohn disease. They may be used in combination with a thiopurine drug (azathioprine or mercaptopurine).
Administration: Biologic drugs are given either as intravenous (IV) injections into the vein or as subcutaneous (under the skin) injections:
- Infliximab is given by IV every 8 weeks
- Adalimumab is given as a subcutaneous injection every other week
- Certolizumab is given as a monthly subcutaneous injection
- Natalizumab is given as a monthly IV
- Vendolizumab is given by IV every 8 weeks
All of these drugs require more frequent administration during the initial weeks of therapy. Sometimes these drugs need to be given more often to keep the disease under control.
Side Effects of Biologics: Biologic drugs can cause pain and swelling at the injection site. Other common side effects may include upper respiratory infections, headache, rash, stomach and back pain, and nausea. Some people have allergic reactions to these drugs.
These drugs may increase the risk for infections, including tuberculosis and reactivation of hepatitis B. People need to be tested for these infections before starting treatment. Your health care provider should monitor you for any signs of viral, bacterial, or fungal infection. People who take biologic drugs should also receive regular tests for signs of liver problems.
The anti-TNF drugs (infliximab, adalimumab, and certolizumab) can increase the risk for lymphomas and leukemia cancers. However, evidence suggests that the risk is relatively rare. The benefits of these drugs appear to outweigh the risks for cancer.
Natalizumab may increase the risk for a rare neurological condition called progressive multifocal leukoencephalopathy (PML), which can lead to death or severe disability. The risk for PML increases when patients have more than 24 infusions of natalizumab (2 years of treatment). PML may also be a risk with vendolizumab but it is too early to tell. Vendolizumab was approved in 2014 and is the newest drug for Crohn disease.
Antibiotics: Antibiotics may be used as a first-line treatment for mild Crohn disease and for treating:
- Bacterial overgrowth
- Infections around the anus and genital areas
Standard antibiotics include ciprofloxacin (Cipro, generic) and metronidazole (Flagyl, generic). Ciprofloxacin is the antibiotic of choice.
Over time, metronidazole can cause peripheral neuropathy, a nerve disorder that can cause numbness and tingling in the hands and feet. Other side effects associated with metronidazole include nausea, vomiting, diarrhea, loss of appetite, dizziness, and headaches.
Although ciprofloxacin causes fewer side effects than metrondizaole, it can interact with antacids (Rolaids, Tums) and vitamin and mineral supplements that contain calcium, iron, or zinc. Do not take antacids or vitamin supplements at the same time as the ciprofloxacin dose. You should also avoid sun exposure as ciprofloxacin increases sun sensitivity. Ciprofloxacin may also increase susceptibility to Clostridium difficile colitis, an antibiotic-associated bacterial infection that causes severe diarrhea.
Anti-Diarrheal Drugs: Mild-to-moderate diarrhea may be reduced by daily use of psyllium (Metamucil, generic). Standard anti-diarrheal medications include loperamide (Imodium, generic) or a combination of atropine and diphenoxylate (Lomotil, generic).