What medications are used to treat Inflammatory Bowel Disease (IBD)?

Medications for Inflammatory Bowel Disease (IBD) Treatment

The cornerstone medications for treating Inflammatory Bowel Disease include aminosalicylates for mild to moderate disease, corticosteroids for acute flares, immunomodulators and biologics for moderate to severe disease, with treatment selection based on disease type, location, severity, and patient-specific factors. 1

First-Line Medications

Aminosalicylates (5-ASA)

• Ulcerative Colitis (UC): First-line therapy for mild to moderate disease
  • Mesalazine (4 g/day) for induction of remission 1
  • Maintenance dosing for preventing relapse 1
  • Available in various formulations: oral tablets, sachets, suspensions, enemas, suppositories 1
  • Delivery systems include pH-dependent release (Asacol, Salofalk), time-controlled release (Pentasa), and carrier molecules (sulfasalazine, olsalazine, balsalazide) 1
• Crohn's Disease (CD): Less effective than in UC
  • May be sufficient for mild ileocolonic disease (4 g/day) 1
  • Can reduce post-surgical relapse, especially after small bowel resection 1

Corticosteroids

• For acute flares in moderate to severe disease:
  • Oral prednisolone (40 mg/day), tapered over 8 weeks 1
  • Budesonide (9 mg/day) for isolated ileo-cecal disease - less systemic effects 1
  • IV steroids (hydrocortisone 400 mg/day or methylprednisolone 60 mg/day) for severe disease 1
• Caution: Should be avoided when possible due to side effects; not suitable for long-term maintenance 1

Second-Line and Advanced Therapies

Immunomodulators

• Thiopurines: Azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.5 mg/kg/day)
  • Used as steroid-sparing agents and for maintenance 1
  • Slow onset of action precludes use as sole therapy for active disease 1
  • Higher risk of lymphoma and non-melanoma skin cancer in elderly patients 1

Biologics

• Anti-TNF agents:

  • Infliximab (IV): Effective for induction and maintenance of remission in CD and UC 2
  • Adalimumab (SQ): Effective for induction of clinical remission (36% vs 12% placebo) and maintenance (40% vs 17% placebo) in CD 3
  • Consider as monotherapy initially to promote home care 1

• Anti-integrin therapy:

  • Vedolizumab: Gut-selective action with favorable safety profile, especially in higher-risk patients 1

• Anti-IL-12/23 therapy:

  • Ustekinumab: Requires one IV induction dose followed by subcutaneous maintenance 1
  • May be preferred in patients with higher risk of complications 1

• JAK inhibitors:

  • Tofacitinib: For UC; caution in patients with cardiac risk factors due to increased risk of venous thromboembolism 1

Adjunctive Therapies

• Antibiotics:

  • Metronidazole (10-20 mg/kg/day): Can be effective but not first-line due to side effects 1
  • Used for perianal disease, bacterial overgrowth, or in combination with IV steroids 1

• Nutritional Support:

  • Elemental or polymeric diets as adjunctive therapy 1
  • Can induce remission in selected CD patients who have contraindications to corticosteroids 1
  • Total parenteral nutrition for complex, fistulating disease 1

Treatment Selection Based on Disease Severity

Mild to Moderate Disease

• UC: 5-ASA compounds (oral and/or topical based on disease extent)
• CD: 5-ASA for mild ileocolonic disease; budesonide for ileal/right-sided disease

Moderate to Severe Disease

• Initial: Corticosteroids (prednisolone or budesonide based on location)
• Maintenance: Immunomodulators or biologics based on response and risk factors

Severe/Refractory Disease

• IV steroids with consideration for early biologics
• Surgical consultation for UC patients not responding to medical therapy 1

Special Considerations

• COVID-19 Risk Stratification: Medications like 5-ASA, topical steroids, and antidiarrheal agents are considered lowest risk; biologics and immunomodulators carry moderate risk 1

• Elderly Patients: Consider vedolizumab or ustekinumab due to better safety profiles; use thiopurines with caution due to increased lymphoma risk 1

• Pain Management: Consider neuromodulators (low-dose tricyclic antidepressants, SNRIs) for chronic pain in IBD patients 1

Common Pitfalls to Avoid

1. Prolonged corticosteroid use: Should be tapered according to response, generally over 8 weeks; rapid reduction associated with early relapse 1

2. Delayed escalation of therapy: Don't hesitate to advance to biologics when appropriate; prolonged steroid use increases complications 1

3. Stopping medications without consultation: Advise patients not to stop or reduce medications without discussing with their IBD team due to risk of flare 1

4. Overlooking disease monitoring: Regular assessment of disease activity is essential for optimizing treatment

5. Ignoring comorbidities: Consider patient's age, comorbidities, and risk factors when selecting therapy 1