Yes! In the past, patients were treated only when they had symptoms to minimize exposure to the drugs used. However, we now appreciate that Crohn's disease may be active even when you don't have any symptoms at all. The goals of treatment are to make you feel better, but also to suppress silent disease activity. Suppressing disease that you can't feel is important not only to prevent future flares, but also to prevent irreversible bowel damage.
Prednisone is a steroid, similar to the steroids that our body naturally makes in response to stress or illness. Prednisone suppresses the immune system and reduces inflammation, which is why it has been used in many inflammatory conditions, including Crohn's and ulcerative colitis. In the short term prednisone can help quickly control disease inflammation, however it has a number of undesirable and dangerous effects when used for too long. Immediate side effects include mood changes (sometimes severe), changes in appetite, insomnia, blurry vision, and acne. When used for many months prednisone also causes severe weakening of the bones (osteoporosis), diabetes, easy bleeding, swelling of the face and legs, and other hormone related side effects. Prednisone can help you feel better in the short term, however number studies have shown there is no long-term benefit to using prednisone. In addition, steroids make it very hard for wounds to heal and leave you very susceptible to infection. People that are on steroids that require surgery are 10–20 times more likely to have a severe problem after surgery due to steroid use. Because of the lack of long-term benefit and high likelihood of severe health problems with long-term use, we do not use prednisone except in special situations.
Aminosalicylates are a type of medicines used to treat ulcerative colitis. They are most often called 5-ASAs, which is short for 5-aminosalicylic acid. 5-ASAs work on the lining of the gut to reduce inflammation by decreasing things that cause inflammation. 5-ASAs work better for ulcerative colitis than for Crohn's disease because ulcerative colitis affects only the lining of the intestines, whereas Crohn's disease affects the deeper layers of the intestines.
5-ASAs are the first choice to treat mild to moderate ulcerative colitis. ASAs are very effective at reducing inflammation which decreases symptoms and prevents flares. ASAs work for about 75% of those with ulcerative colitis. When you take a 5-ASA regularly, it also helps to protect you from developing colon cancer. These medicines work only when the colon is affected by the disease.
Some of the 5-ASA medications are taken by mouth; others are given as a suppository (Canasa) or an enema (Rowasa). Very often, oral and rectal mediations are given together for improved disease control.
5-ASAs generally cause very few side effects. The most common and less serious side effects of 5-ASAs include headache, abdominal pain, belching, nausea, diarrhea, and pharyngitis (sore throat). The enema and suppository form of mesalamine cause even fewer side effects. Signs that your body is not able to tolerate these medicines include cramping, severe abdominal pain, and bloody diarrhea, and sometimes fever, headache, or rash. Call your health care team right away as you may need to stop taking the medicine. How is your doctor watching this? Shouldn't the patient be watching and call right away. Do not be alarmed; 5-ASAs may turn your urine to a brown-yellow color.
As noted above, 5-ASAs can cause kidney problems but this is very rare. 5-ASAs may also make the varicella (chickenpox) vaccine more toxic. This is called Reye's syndrome and occurs in children. Children should never be given aspirin and 5-ASAs while they are ill with chickenpox or have just received the chickenpox vaccine.
Azathioprine and 6-MP are purine synthesis inhibitors, which have been used for over 30 years in Crohn's disease and ulcerative colitis, rheumatoid arthritis, and for organ transplants. By decreasing the number of white blood cells that are made these medications reduce the activity of your immune system enough to control the inflammation, but not so much to leave you susceptible to a lot of infection. A majority of patients with IBD find this medication to be very effective.
Every medication has some potential for side effects. It is possible to have side effects when on azathioprine, including headaches, nausea, rash, or fever. Imuran sometimes can work too well and reduce your white blood cell count too much. This can make you potentially more susceptible to some infections. For this reason we will perform regular blood work to help assure your safely. Rarely, pancreatitis can occur in people taking azathioprine.
There is an increased risk of some cancers when using azathioprine, including skin cancer and lymphomas. The risk of lymphoma is increased by 2–4 times. However, because these complications are still relatively rare, in many cases the potential benefits for controlling the Crohn's disease far outweigh these potential risks.
Azathioprine dose is personalized and is determined by multiple factors including your weight, genetics, and other medications you may take. Don't be surprised if your doctor occasionally increases or decreases the dose, this is common. Also keep in mind that it typically takes 6–12 weeks to notice the effects of azathioprine or 6-MP.
There are three anti-TNF medicines used to treat Crohn's disease and ulcerative colitis: infliximab (Remicade®), adalimumab (Humira®), and certolizumab pegol (Cimzia®). Anti-TNF-alpha medications suppress the immune system by blocking a very specific agent called tumor necrosis factor (TNF). There are many chemicals in your body that cause and regulate inflammation. TNF appears to be very important in inflammatory bowel disease. These medications are antibodies that bind to and block the activity of TNF. These medications are often used when azathioprine or methotrexate are not sufficient. In some individuals, there are factors that indicate Anti-TNF medications should be used before azathioprine or methotrexate.
Remicade is an IV infusion, it was the first anti-TNF medication that was effective in inflammatory bowel disease. After an induction period, it is given every 6–8 weeks. Patients come to an outpatient infusion center, get an IV line placed, and the drug is infused over 1–3 hours. Humira and Cimzia are both anti-TNF agents that you administer to yourself at home. It takes time to measure the full effect of anti-TNFs; usually 6–12 weeks. Anti-TNFs work best when used long-term. Once started, you should not stop using anti-TNFs unless stopped by your physician; missing doses or stopping these medications often leads to a loss of effectiveness.
Likely all immune suppressants, anti-TNFs generally increase the chance of infection and some cancers. However, the possible risks of these medications are very often far outweighed by the benefits. People may have an allergic reaction or other common side effects like headaches or rash. Always talk to your doctor if you are experiencing side effects as sometimes it is in your interest to tolerate these side effects, whereas in some situations the drug must be stopped.
There are a few specific infections that require attention when using anti-TNF agents. Tuberculosis (or TB) is a serious bacterial infection. Some people may have TB that is dominant but can reactivate and cause problems after starting an anti-TNF. People at risk of having dormant TB are healthcare workers, people who have been in or worked in prison, military stationed overseas, people who have lived in Central America, Mexico, or Eastern Europe. We test patients for TB prior to starting anti-TNF medications using a blood or skin test. hepatits B and C can get worse when people start anti-TNF medications. Fungal infections like histoplasmosis also occur more frequently for people on immunosuppressants, especially anti-TNF agents. If you develop shortness of breath, sustained fever of over 101.0 degrees, or a chronic cough, let your doctor's office know right away. These medications increase your risk for other infections, if you develop an infection contact your doctor for instruction on what to do with your anti-TNF medication.
There is an increased risk of lymphoma when using anti-TNF agents. Your doctors are aware of these considerations and carefully use anti-TNFs and all immunosupressants when we believe you have a lot to gain from the medications.
Methotrexate reduces the activity of your immune system in a different way than azathioprine or 6-mercaptopurine. Methotrexate has been used for over 40 years so we know a lot about how to use it and know that it is safe to use this medicine for a longtime. Methotrexate has been shown to significantly improve symptoms and prevent future symptoms. It is available as a pill or injection; however, the injection has been shown to be better in inflammatory bowel disease. Like with azathioprine and 6-MP, you need have regular blood work performed for your safety. As with all medications there are some risks. Methotrexate can suppress your bone marrow (lower your blood counts), it can cause liver and lung problems very rarely. Some people will experience nausea and fatigue after taking methotrexate. All immunosupressants to increase your general risk of infection; however, this is not often a problem when using methotrexate at low doses. Patients often notice an improvement in symptoms 4–8 weeks after starting methotrexate.