A Guide to Crohn's Disease Drugs
There is no cure for Crohn's disease, a type of inflammatory bowel disease. But there are many effective drugs that can treat the symptoms.
"There are a lot of sophisticated ways drugs are combined and for different purposes," says Arthur DeCross, MD, associate professor of medicine at the University of Rochester Medical Center in Rochester, New York.
Here are some 12 different types of drugs and how they can help make life easier for people with Crohn's.
- Corticosteroids, usually prednisone, can provide rapid relief of pain and diarrhea. In general, these very effective medications aren't appropriate for long-term use because of side effects, such as bloating, excessive facial hair, sleep disruption and, even an increased risk of diabetes and osteoporosis.
- Corticosteroids for Crohn's disease can be taken in pill form, rectally, or intravenously, and generally start working within days.
Budesonide (Entocort) is a corticosteroid that tends to have fewer side effects. "The liver metabolizes it very, very quickly," says Dr. DeCross. "It's useful in mild-to-moderate cases and can be used for weeks to months without getting into prednisone side effects."
Entocort targets the ileum (the lower part of the small intestine) and the first part of the large intestine. But Entocort is not nearly as powerful as prednisone so it's not likely to be as helpful in people with severe Crohn's disease, says Dr. DeCross.
Azathioprine and mercaptopurine
Azathioprine (Imuran) and mercaptopurine (Purinethol) dampen the overactive immune response seen in Crohn's.
These drugs are often slow-acting, with an average response time of about three months, says Dr. DeCross. "It also takes a lot of fussing and finesse to get the drug levels just right and monitor the body for adverse effects but, once you establish the dosage, they can be effective in the long-term," Dr. DeCross says. Side effects can include infections as well as nausea and vomiting, pancreatitis, and elevated liver function tests.
Sulfasalazine (Azulfidine), one of a class of drugs known as aminosalicylates, can ease inflammation in mild-to-moderate disease and can help keep people in remission, Dr. DeCross says.
The good news? It comes in pill form and is relatively inexpensive. The bad news? It's a sulfa drug so anyone with a sulfa allergy needs to stay away from it. It can also have unpleasant side effects including nausea, vomiting, headache, and heartburn.
Mesalamine (Asacol, Pentasa) is also an aminosalicylate and may be helpful for those allergic to sulfa drugs.
It comes in a pill form, enema (Rowasa), or suppository (Canasa).
Many doctors have stopped using mesalamine because the research has been mixed on its efficacy, says Nirmal Kaur, MD, medical director of the Inflammatory Bowel Disease Center at Henry Ford Health System in Detroit. "It has fallen out of favor."
Olsalazine (Dipentum) and balsalazide (Colazal), which are closely related to mesalamine, may represent other options.
Antibiotics are often used in addition to other medications, particularly for mild-to-moderate Crohn's disease to help establish a remission or in treatment of fistulas. But they aren't long-term solutions, says Dr. DeCross. Metronidazole (Flagyl) is what's known as a broad-spectrum antibiotic, meaning it is effective against many different types of bacteria that may erupt as the result of a stricture or fistulas or after surgery. Metronidazole may cause side effects, such as numbness and tingling in your hands and feet and muscle pain or weakness.
Infliximab (Remicade) is a biologic, a therapy that uses or mimics naturally occurring molecules to treat disease.
Biologics work relatively rapidly (within a couple of weeks) but are usually used for more severe disease, or in those with bowel obstructions or fistulas (abnormal connections, including abscesses, between parts of the body), says Dr. Kaur.
Because these drugs suppress the immune system, they can have side effects, including a risk of serious infection. Remicade is given by intravenous infusion ever few weeks.
Like Remicade, the biologic agent Certolizumab pegol (Cimzia) is generally reserved for more severe cases. "You're not going to need to clobber mild-to-moderate cases of Crohn's disease with something as powerful as a biologic," says Dr. DeCross. Biologics can be particularly useful for fistulas. One note of caution: going on and off the drugs can lead to resistance, says Dr. DeCross, so they should be used thoughtfully. The drug is delivered as an intravenous drip via intramuscular injection.
Adalimumab (Humira) is the third in the set of powerful biologic agents generally reserved for more severe Crohn's. It works in the same way, by blocking tumor necrosis factor, a protein overproduced in Crohn's.
Humira is delivered by an initial injection followed by patient-administered self-injections every two weeks. People may experience pain and irritation at the site of the injection while more serious side effects can include a susceptibility to infections, such as tuberculosis or fungal infections.
Natalizumab (Tysabri), another biologic, affects a different part of the immune system and may be helpful in people who can't take the TNF inhibitors Remicade, Humira, and Cimzia.
The drug, which is given by intravenous infusion, tends to be reserved used for moderate-to-severe cases of Crohn's. It carries a heightened risk of infections, including multifocal leukoencephalopathy, a severe brain infection.
Because of this, people generally take it as part of a restricted program that includes monitoring.
Originally a chemotherapy drug used to treat leukemia and other cancers, methotrexate is sometimes used for Crohn's disease.
"It's a great therapy that can be very effective in the right clinical settings," says Dr. Kaur. However, women of child-bearing age need to use birth control while taking it because it can cause birth defects.
Methotrexate, which is given by weekly injections or oral tablets, can also raise the risk of infections like some other Crohn's drugs.
Diarrhea is a common and unpleasant symptom of Crohn's but over-the-counter anti-diarrheal remedies may bring some relief.
"There's no harm in using an anti-diarrhea like Imodium [loperamide] or Lomotil [diphenoxylate] to bring additional symptom relief," says Dr. DeCross.