The wonderful world of IBD medications

From physician to remission

Right now there is no cure for IBD. The main goal then is to find a medication that will put you into remission (heal the lining of your GI tract) and keep you in remission. For some, this will be a relatively straightforward process: you find a med that works and stay on it (“maintenance”). Likely forever. Or until they find a cure for IBD. Or until your body develops a resistance to the med.

Sometimes (after years or even decades) your body may develop antibodies to a med, and the med may stop working. This is not the end of the world – usually all you have to do is switch to a different med in a similar pharmaceutical class and it will put you back into remission.

But for others, like myself, the process is a bit more “trial and error”. You may need to trial two or three meds (or more) before you find the one that “works” for you. Or you might have to try multiple classes of meds (more on this later), or different med combinations. Rest assured, your GI doc will follow treatment guidelines based on your disease presentation, so treatment regimens are all somewhat standardized. It’s not all willy-nilly guess work.

Some people may find a drug that “kind of” works for them. A small subset of people may never find a med that fully works for them. Others may opt for surgical treatment too, if that is an option. The good news though is that a significant majority of people will find relief (or remission) from taking IBD medication under the supervision of a GI physician. However, the exact stats vary med-to-med, and due to a bajillion other factors…so it is very hard to accurately predict how a person will respond to a given med.

Going au naturale

Some individuals may opt to take a more natural approach (diet, lifestyle, supplements, etc.) and forgo pharmaceutical IBD medications. While this may work for a small number of individuals, most GI docs would strongly caution against this course of action. At present, there is an overwhelming body of medical studies and clinical trials which demonstrate the safety and effectiveness of pharmacological IBD treatments (no I don’t work for a pharma company!) That is not to say things like diet and lifestyle are not important – they definitely are. However, consensus has yet to be reached in the medical community over the extent to which those play a role in healing.

The IBD medication menu

The five key classes of IBD medications are described below in brief. Some people may only need to take a single med to control their IBD. Others may need two or 3 meds, each from a different class, to induce and maintain remission.

1. Aminosalicylates (a.k.a. “5-ASA’s”)

• Older class of meds
• Have anti-inflammatory properties
• Often used in mild-moderate disease, especially ulcerative colitis
• Can be either pill-form, liquid, creams, or suppositories
• Typically less expensive and fewer side-effects than other IBD meds, but often less effective than biologics
• Examples: sulfasalazine, mesalamine, olsalazine

2. Immunosuppressives

• Work by weakening the immune system, killing cells which produce the inflammatory response
• Used for moderate-severe disease
• Frequently combined with another med, such as a biologic and/or steroid
• Taken as pills or given as an injection
• Often have a more severe side-effect profile
• Examples: azathioprine, mercaptoprine, methotrexate

3. Corticosteroids

• Reduce inflammation and suppress the immune system
• Used in moderate-severe disease
• Powerful and fast-acting: reduce symptoms quickly (often within days)
• Short courses usually induce remission, then the steroid is tapered and eventually stopped so a second medication can “take over” (e.g. biologics) to maintain remission
• Should not be used long-term, as they can have a number of undesirable side-effects
• Taken as pills, creams, suppositories/enemas or IV (in hospital)
• Examples: prednisone, dexamethasone, hydrocortisone, budesonide

4. Biologics

• Reduce inflammation by targeting and blocking specific proteins and enzymes which cause inflammation
• Do not suppress the immune system to the same degree as steroids and immunomodulators
• Expensive!
• Side-effects vary, but they are usually fairly well-tolerated
• Used in both induction and long-term for maintenance treatment
• Given by self-injection at home, or via IV infusion (at hospital or clinic)
• Examples: Remicade, Humira, Cimzia, Entyvio, Stelara,
• “Biosimilars” are drugs which are similar in structure to biologics, but cheaper and have comparable effectiveness in most people. They are sort of like the “generic versions” of biologics, but not exactly.

5. New Small Molecule drugs (a.k.a. JAK inhibitors)

• Newer medications that reduce inflammation through blocking enzymes associated with inflammation in the body
• Expensive!
• Taken in pill/tablet form
• Currently only approved for treatment of ulcerative colitis
• May have more side-effects than other meds because they are not as focused or targeted
• Examples: Xeljanz, Jyseleca, Rinvoq

Lastly, depending how your IBD presents, other medications could be prescribed. For example, antibiotics and/or drugs to reduce gastric acid may be used to promote healing of the GI tract and increase the likelihood of inducing remission.

“Step-up” vs. “Top-down” approaches

The traditional approach to IBD management is to begin with the lower classes of medications (5-ASA’s) first, which are cheaper and usually have less side-effects. Then, if those medications fail to produce adequate clinical response, the GI doctor will move “up the medication ladder” and prescribe increasingly stronger medications if needed (like biologics). Unfortunately, these stronger medications are often much more expensive, and may also have more severe side-effects (but not always).

In contrast, new data is starting to show that a better way to induce GI healing, and improve IBD symptoms, may be with early, aggressive therapy. Thus, stronger drugs (like biologics) are used as a first-line therapy, often in conjunction with steroids and/or immunosuppressives, to “knock down” the GI inflammation as quickly as possible.

More good news for people living with IBD: several new medications are usually approved and released every year or so, especially biologics…so the number of medication options is increasing. This is a good thing. Some of the newer medications are also more targeted (“gut-specific”), more effective (hopefully) and are associated with fewer side-effects.

From diagnosis to the prescription pad

A ton of factors will affect what IBD medication(s) your GI doctor chooses to prescribe. This includes your age, disease extent and severity, whether you have Crohn’s or UC, as well as the results of scopes, scans, and blood/stool tests.

This is why it is so important to establish a good therapeutic relationship with your GI. Make sure you do your research before appointments (use trusted sources, not Facebook!) Bring a list of questions with you. During the consult, take notes. Get the doctor to clarify anything you don’t understand. Pro-tip: bring a support person with you as a second pair of ears if you can.

Other considerations may also play a role in a person’s decision to start or continue an IBD med:

• Drug cost, co-pay and health insurance coverage *** some drug manufacturers will provide rebates or coupons for those who are unable to afford the cost of medication – ask your GI, pharmacist or treatment coordinator
• Whether you live in a rural area, or an urban area close to a major care center/clinic
• If you experience intolerable side-effects from a med, or have an allergic response to a med
• The route of drug administration (pill, injection, infusion, enema, etc.)
• If you have any pre-existing medical conditions

In short, going on medication for IBD is a huge decision. It can be scary. But, for an overwhelming majority of people, medication will lead to improvements in IBD symptoms and overall quality of life.

No two Crohn’s or colitis cases are exactly alike, so there is no “one size fits all” approach to medication and treatment. The medications your doctor prescribes for you, the dosage, and the effects you may experience are going to be unique to you. You and your physician must work together to sort out what is the most effective plan for you when you are in a flare-up or in remission. You got this!

Stay tuned for the next post, where I will be discussing my own experiences with IBD medications.

And, as always, be gentle with yourselves.

Disclaimer: I am not a doctor. The above post is for information purposes only.

Useful (and trusted) websites for more IBD medication information:

Crohn’s and Colitis Foundation Canada: https://crohnsandcolitis.ca/About-Crohn-s-Colitis/IBD-Journey/Treatment-and-Medications

Crohn’s and Colitis Foundation (US): https://www.crohnscolitisfoundation.org/what-is-ulcerative-colitis/medication

Canadian GI Society – badgut.org: https://badgut.org/information-centre/a-z-digestive-topics/inflammatory-bowel-disease/