Treatments and drugs

By Mayo Clinic Staff

The goal of inflammatory bowel disease treatment is to reduce the inflammation that triggers your signs and symptoms. In the best cases, this may lead not only to symptom relief but also to long-term remission. IBD treatment usually involves either drug therapy or surgery.

Anti-inflammatory drugs

Anti-inflammatory drugs are often the first step in the treatment of inflammatory bowel disease. They include:

  • Sulfasalazine (Azulfidine). Sulfasalazine can be effective in reducing symptoms of ulcerative colitis, but it has a number of side effects, including nausea, vomiting, diarrhea, heartburn and headache. Don't take this medication if you're allergic to sulfa medications.
  • Mesalamine (Apriso, Asacol, Lialda, others), balsalazide (Colazal) and olsalazine (Dipentum). These medications are available in oral forms, and also in topical forms, such as enemas and suppositories. Which form you take depends on the area of your colon that's affected. These medications tend to have fewer side effects than sulfasalazine, and are generally very well tolerated.
  • Corticosteroids. Corticosteroids can help reduce inflammation, but they have numerous side effects, including weight gain, excessive facial hair, mood swings, high blood pressure, type 2 diabetes, osteoporosis, bone fractures, cataracts, glaucoma and an increased susceptibility to infections. Doctors generally use corticosteroids only if you have moderate to severe inflammatory bowel disease that doesn't respond to other treatments. Corticosteroids aren't for long-term use and the dose is usually tapered down over two to three months.

Immune system suppressors

These drugs also reduce inflammation, but they target your immune system rather than treating inflammation itself. Because immune suppressors can be effective in treating ulcerative colitis, scientists theorize that damage to digestive tissues is caused by your body's immune response to an invading virus or bacterium or even to your own tissue. By suppressing this response, inflammation is also reduced. Immune system suppressors are associated with a small risk of developing cancer, such as lymphoma. Immunosuppressant drugs include:

  • Azathioprine (Azasan, Imuran) and mercaptopurine (Purinethol). Because azathioprine and mercaptopurine act slowly — taking three months or longer to start working — they're sometimes initially combined with a corticosteroid. With time, they seem to produce benefits on their own and the steroids may be tapered off.
  • Side effects can include allergic reactions, bone marrow suppression, infections, and inflammation of the liver and pancreas. There also is a small risk of development of cancer with these medications. If you're taking either of these medications, you'll need to follow up closely with your doctor and have your blood checked regularly to look for side effects. If you've had cancer, discuss this with your doctor before starting these medications.

  • Cyclosporine (Gengraf, Neoral, Sandimmune). This potent drug is normally reserved for people who don't respond well to other medications or who face possible surgery because of severe ulcerative colitis. In some cases, cyclosporine may be used to delay surgery until you're strong enough to undergo the procedure. It may also be used to control signs and symptoms until less toxic drugs start working. Cyclosporine begins working in one to two weeks, but because it has the potential for severe side effects, including kidney damage, seizures and fatal infections, talk to your doctor about the risks and benefits of treatment. There's also a small risk of cancer with these medications, so let your doctor know if you've previously had cancer.
  • Infliximab (Remicade). This drug is specifically for those with moderate to severe ulcerative colitis who don't respond to or can't tolerate other treatments. It works quickly to bring on remission, especially for people who haven't responded well to corticosteroids. It works by neutralizing a protein produced by your immune system known as tumor necrosis factor (TNF).
  • Some people with heart failure, people with multiple sclerosis, and people with cancer or a history of cancer can't take infliximab. The drug has been linked to an increased risk of infection, especially tuberculosis and reactivation of viral hepatitis, and may increase your risk of blood problems and cancer. You'll need to have a skin test for tuberculosis, a chest X-ray and a test for hepatitis B before taking infliximab.

  • Adalimumab (Humira).Adalimumab works similarly to infliximab by blocking TNF for people with moderate to severe Crohn's disease. It can be used soon after you're diagnosed if you have a fistula, or if you have more severe Crohn's disease. It also may be used after other medications have failed to improve your symptoms. Adalimumab may be used instead of infliximab or certiluzimab, or it can be used if infliximab or certiluzimab stop working. Adalimumab may reduce the signs and symptoms of Crohn's disease and may cause remission.
  • However, adalimumab, like infliximab, carries a small risk of complications, including tuberculosis and serious fungal infections. Your doctor will give you a skin test for tuberculosis, obtain a chest X-ray and test you for hepatitis before you begin adalimumab treatment. The most common side effects of adalimumab are skin irritation and pain at the injection site, nausea, runny nose and upper respiratory infection.

  • Certolizumab pegol (Cimzia). Approved by the Food and Drug Administration for the treatment of Crohn's disease, certolizumab pegol works by inhibiting TNF. Certolizumab pegol is prescribed for people with moderate to severe Crohn's disease. Certolizumab pegol may be used instead of infliximab, or it can be used if infliximab or adalimumab stop working. Common side effects include headache, upper respiratory infections, abdominal pain, nausea and reactions at the injection site. Because this drug affects your immune system, you're also at risk of becoming seriously ill with certain infections, such as tuberculosis. Your doctor will give you a skin test for tuberculosis, obtain a chest X-ray and test you for hepatitis before you begin certiluzimab pegol.
  • Methotrexate (Rheumatrex)zThis drug, which is used to treat cancer, psoriasis and rheumatoid arthritis, is sometimes used for people with Crohn's disease who don't respond well to other medications. Short-term side effects include nausea, fatigue and diarrhea, and rarely, it can cause potentially life-threatening pneumonia. Long-term use can lead to scarring of the liver and sometimes to cancer. Avoid becoming pregnant while taking methotrexate. If you're taking this medication, follow up closely with your doctor and have your blood checked regularly to look for side effects.
  • Natalizumab (Tysabri). This drug works by inhibiting certain immune cell molecules — integrins — from binding to other cells in your intestinal lining. Natalizumab is approved for people with moderate to severe Crohn's disease with evidence of inflammation and who aren't responding well to other conventional Crohn's disease therapies. Because the drug is associated with a rare, but serious, risk of multifocal leukoencephalopathy — a brain infection that usually leads to death or severe disability — you must be enrolled in a special program to use it.

Antibiotics

Antibiotics can reduce the amount of drainage and sometimes heal fistulas and abscesses in people with Crohn's disease. Researchers also believe antibiotics help reduce harmful intestinal bacteria and suppress the intestine's immune system, which can trigger symptoms. However, there's no strong evidence that antibiotics are effective for Crohn's disease. Frequently prescribed antibiotics include:

  • Metronidazole (Flagyl). Once the most commonly used antibiotic for Crohn's disease, metronidazole can cause serious side effects, including numbness and tingling in your hands and feet and, occasionally, muscle pain or weakness.
  • Ciprofloxacin (Cipro). This drug, which improves symptoms in some people with Crohn's disease, is now generally preferred to metronidazole. A rare, but possible side effect of this medication is tendon rupture.

Other medications

In addition to controlling inflammation, some medications may help relieve your signs and symptoms. Depending on the severity of your inflammatory bowel disease, your doctor may recommend one or more of the following:

  • Anti-diarrheals. A fiber supplement, such as psyllium powder (Metamucil) or methylcellulose (Citrucel), can help relieve mild to moderate diarrhea by adding bulk to your stool. For more severe diarrhea, loperamide (Imodium) may be effective.
  • Laxatives. In some cases, swelling may cause your intestines to narrow, leading to constipation. Talk to your doctor before taking any laxatives, because even those sold over-the-counter may be too harsh for your system.
  • Pain relievers.For mild pain, your doctor may recommend acetaminophen (Tylenol, others). Avoid ibuprofen (Advil, Motrin, others), naproxen (Aleve) and aspirin. These are likely to make your symptoms worse.
  • Iron supplements. If you have chronic intestinal bleeding, you may develop iron deficiency anemia. Taking iron supplements may help restore your iron levels to normal and reduce this type of anemia once your bleeding has stopped or diminished.
  • Nutrition. Your doctor may recommend a special diet given via a feeding tube (enteral nutrition) or nutrients injected into a vein (parenteral nutrition) to treat your Crohn's disease. This can improve your overall nutrition and allow the bowel to rest. Bowel rest can reduce inflammation in the short term.
  • B-12 shots.Vitamin B-12 helps prevent anemia, promotes normal growth and development, and is essential for proper nerve function. It's absorbed in the terminal ileum, a part of the small intestine often affected by Crohn's disease. If inflammation of your terminal ileum is interfering with your ability to absorb this vitamin, you may need monthly B-12 shots for life. You'll also need lifelong B-12 injections if your terminal ileum has been removed during surgery.
  • Calcium and vitamin D supplements. You may need to take a calcium supplement with added vitamin D. This is because Crohn's disease and steroids used to treat it can increase your risk of osteoporosis. Ask your doctor if a calcium supplement is right for you.
  • Surgery

    If diet and lifestyle changes, drug therapy, or other treatments don't relieve your IBD signs and symptoms, your doctor may recommend surgery.

    • Surgery for ulcerative colitis. Surgery can often eliminate ulcerative colitis. But that usually means removing your entire colon and rectum (proctocolectomy). In the past, after this surgery you would wear a small bag over an opening in your abdomen (ileostomy) to collect stool. But a procedure called ileoanal anastomosis eliminates the need to wear a bag and is the preferred procedure for most people. Your surgeon constructs a pouch from the end of your small intestine. The pouch is then attached directly to your anus. This allows you to expel waste more normally.
    • Surgery for Crohn's disease. In Crohn's disease, surgery can provide years of remission at best. At the least, it may provide a temporary improvement in your signs and symptoms. During surgery, your surgeon removes a damaged portion of your digestive tract and then reconnects the healthy sections. In addition, surgery may also be used to close fistulas and drain abscesses. A common procedure for Crohn's is strictureplasty, which widens a segment of the intestine that has become too narrow.

    Cancer surveillance

    People who have inflammatory bowel disease have an increased risk of colon cancer. Talk with your doctor about how often you should be screened.

Dec. 13, 2012

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