Living with Crohn’s disease or ulcerative colitis is challenging (ahem…understatement). And navigating the world of IBD medications can be scary and confusing. However, knowing about your treatment options can make things a little easier.
One of the big improvements in recent years is the use of biologic medications. In this post, I will explore what these medications are, how they can help, and what you need to know to make the best choices for your health.
What are biologic medications?
Biologic medications (a.k.a “biologics”) are treatments made from living cells. If a drug ends in a “mab” or a “umab” (like “adalimubab”)…chances are it’s a biologic.
Besides sounding funny and being hard to pronounce, biologic drugs are designed to work on specific parts of your immune system that cause inflammation. Unlike older drugs that affect your entire body (I’m talking to you, prednisone!), biologics target the problem area more directly.
How do biologics work for IBD?
Biologics work by specifically targeting and blocking proteins or cells in the immune system that cause inflammation. This helps to reduce inflammation, lesions, and ulceration in the gut, leading to fewer IBD symptoms and allowing the intestines to heal.
There are several main types of biologics:
- TNF Blockers:
These medications stop a protein in intestinal cells called TNF (“tumor necrosis factor”) from causing inflammation. Some common examples are:
- Infliximab (Remicade): given as a 3-4 hour infusion, usually every 8 weeks after initial loading doses
- Adalimumab (Humira): self-administered via an auto-injector pen, usually every 2 weeks after initial loading doses
- Certolizumab (Cimzia): self-administered subcutaneously via pre-filled syringes, usually every 4 weeks after loading doses
- Integrin Blockers:
These drugs block specific immune cells from entering the gut and causing inflammation. Examples include:
- Vedolizumab (Entyvio): ~30-minute infusion given every 8 weeks after loading doses
- Natalizumab (Tysabri): 1-hour infusions given every 4 weeks after loading doses
- IL-12/IL-23 Blockers:
These medications block proteins called IL-12 and IL-23 that are involved in inflammation. One example is:
- Ustekinumab (Stelara): self-administered subcutaneously via a pre-filled syringe every 8-12 weeks after initial loading doses
Recently-approved biologics for IBD
Commercials for new biologics are plastered all over TV right now. You have probably seen them: people with IBD are all happy and smiling doing fun things outside in the sunshine…then the commercial ends with “Ask your doctor about Skyrizi“. If only life were that simple…
Remember, these new drugs are not necessarily “better”. They are just newer. And they have a crap ton of marketing behind them. Your GI physician will know if one of these brand-new IBD biologics is right for you. It never hurts to ask. Just make sure you have realistic expectations.
- Mirikizumab (Omvoh): IL-23 agonist, initially given as three 30-minute infusions at weeks 0,4, and 8. Afterwards, from week 12, you self-administer 2 injections once every 4 weeks with an auto-injector pen
- Risankizumab (Skyrizi): IL-23 agonist, initially given as three 1 hour infusions at weeks 0, 4, and 8, then every 8 weeks subcutaneously using an auto-injector pen
Which biologic will I be started on?
That is the million dollar question; unfortunately, the answer is not often straightforward. Also, I’m not a doctor.
Sometimes different GI physicians and clinics have different prescribing practices. Other times, it can depend on factors such as health insurance/prescription coverage, provincial/state guidelines, and Pharmacare plans.
Typically, anti-TNF biologics are the first-line treatment (either Remicade or Humira), as they have been around the longest and have the most clinical evidence demonstrating their effectiveness. Some GI doctors may prefer starting you on Remicade; others may use Humira more.
In some instances, your doctor may give you a choice. For example, if you are okay with going into a health clinic for regular infusions every 8 weeks, then you might choose Remicade. On the flip side, if you would rather self-administer injections every couple of weeks, then Humira might be a good choice for you. You may also be given the more cost-effective “biosimilar” version of these medications, which, in most cases, are just as effective.
If you fail to respond to a TNF drug, biologics like Entyvio and Stelara are often considered the second-line. Brand-new biologics like Skyrizi and others may also be used as second-line treatments.
In other cases though, you may be immediately started on Entyvio, or Stelara, or Skyrizi as a first-line treatment…or another biologic. It really varies. GI physicians use complicated algorithms to determine which biologic to start you on, or to switch you to. These algorithms factor in many variables, such as disease type, severity, location, and a host of other factors. It is always good practice to ask your GI doctor their rationale for choosing the biologic you are being prescribed.
Benefits of Biologics for IBD
- Focus on the Problem: Biologics target specific parts of the inflammation process, which can mean fewer side effects compared to older drugs.
- Help for Tough Cases: They can be especially helpful for people who haven’t responded well to other treatments.
- Long-Term Relief: Many patients experience long-term remission with biologics.
- Less Steroid Use: Biologics can often reduce or eliminate the need for steroids, which have many negative side effects.
Considerations and potential side-effects
While biologics have many benefits, there are also some things to be aware of:
- Infections: Biologics can weaken your immune system, making you more prone to infections.
- Injection/Infusion Reactions: Some people may have reactions where the medication is injected or infused through an IV. These reactions can vary from mild to more serious. Some people feel tired or lethargic after administration of a biologic. Allergic reactions happen in a small number of cases.
- Cost: Biologic treatments can be expensive, but many insurance plans cover them. However, assistance programs are often available to help with costs, providing you with the support you need to focus on your health rather than financial worries.
- Regular Monitoring: You will need regular appointments to ensure the medication is working and check for side effects.
Making the Decision
Choosing to start biologic therapy is a big decision, and you should discuss it with your doctor. Here are some questions to ask:
- Why is this specific biologic being recommended for me?
- What are the possible side effects, and how can they be managed?
- How will we know if the treatment is working?
- Are there lifestyle changes or other treatments I need to consider?
- Is there financial assistance available to help pay for the medication?
Final Thoughts
Biologic medications have revolutionized the treatment of IBD, offering new hope and relief for many living with Crohn’s disease and ulcerative colitis. By understanding how these medications work and what to expect, you can make informed decisions about your treatment.
Remember to talk to your doctor about any questions or concerns to find the best treatment plan for you. If one biologic fails to adequately manage your symptoms, fear not! You have options. We are lucky in 2024 that we have so many different options available for IBD treatments and therapeutics.
So stay informed, be proactive, and remember you’re not alone in this. If you and your GI doctor are considering new treatment options, know that a biologic could be the first step towards remission and a better quality of life.