A diagnosis of inflammatory bowel disease (IBD) can be overwhelming. As the list of medications for IBD grows, you may have questions about their uses and risks. This article covers some of the potential benefits and risks of medications for recovery. Options for care don’t stop at medications, of course — addressing your lifestyle can also provide profound support. Your health is unique, and what works for one person will not work for everyone. When it comes to managing IBD and your health, you have options (and support).
What Is Inflammatory Bowel Disease?
Like other autoimmune conditions, IBD results from an overstimulated immune system response. In IBD, the inflammation targets the gastrointestinal (GI) tract. There are two types of IBD: Crohn's disease (CD) and ulcerative colitis (UC). In CD, the immune response causes destructive intestinal inflammation that can occur anywhere between the mouth and anus. In UC, the inflammation affects the innermost mucosa layer in the rectum and colon (large intestine). (Source, Source)
The inflammatory immune response is a normal and effective means for the body to fight off pathogens. As with other autoimmune conditions, IBD is caused by an inflammatory response that fails to shut itself off when no longer needed.
Inflammation response and control are regulated by immune cells, called T cells (specifically “Th17” and “Treg” cells). When inflammatory cells (Th17 cells) are not regulated (by Treg cells), the protective intestinal mucosa layer can be destroyed. Inflammation damage can contribute to symptoms, but symptoms do not always match disease progression. (Source, Source)
What Are the Symptoms of IBD?
Common symptoms of IBD include abdominal pain, unintentional weight loss, diarrhea, and inflammatory symptoms outside the gastrointestinal tract. Bone diseases, such as osteoporosis, osteopenia, and osteomalacia are more common in IBD sufferers and can occur from disease progression or as side effects of IBD medications.
In CD, the inflammatory process can lead to fistulas, or abnormal openings between the GI tract and other internal organs or the surface of the skin. This type of inflammation can lead to permanent damage to the digestive tract. It can require surgery to remove damaged segments of the intestines, and increases the risk of colon cancer. (Source)
What Are the Triggers for IBD?
There are several symptom and inflammation triggers for those with IBD, and they vary with each person. Environmental triggers include bacterial infections, use of medications that affect bacterial balance in the colon, diet, and chronic nutrient deficiencies. If you have IBD, any of these factors could contribute to an overactive immune response. (Source)
Do I Need Medication to Recover From IBD?
If you have been diagnosed with IBD, you may be searching for treatments that will promote the fastest relief of symptoms with the fewest (or least serious) side effects. Despite their potential usefulness in achieving remission of symptoms (i.e., recovery), medications’ side effects and toxicity, and a lack of clarity about their effects, can affect getting to a state of recovery quickly. (Source)
While medications are not the only possible type of IBD treatment, they can play a role in reducing the acute inflammation that is driving damage to the digestive tract. Some medications used to treat IBD can promote mucosal healing, which can make a relapse less likely. (Source)
It is essential to work with a trusted provider who can help you find the right medications and address any concerns or side effects. The more you know about the current medications used to treat IBD, the more comfortable you will be in asking questions and with your recovery plan.
What Is First-Line Therapy?
The first medications given to induce remission in IBD are known as first-line therapy. Rather than a gradual step-up approach, they are chosen to achieve quick recovery with the fewest medications, risks, or side effects. Medications are often chosen to pair with the activity of the immune system and the stage of disease progression.
Each medication has limited efficacy and is carefully selected by your health care provider based on your clinical signs and symptoms, age, and pregnancy status. Genetic and lifestyle factors may also affect your response to a particular medication and should be taken into consideration.
Medical treatment goals are to induce or maintain remission and improve symptoms and quality of life, while reducing drug toxicity and the need for surgery. (Source)
What Are the Current Inflammatory Bowel Disease Medications?
There are 3 main groups of medications used to treat IBD: anti-inflammatory, immunosuppressive, and immunomodulatory. Despite the different categories, all groups address immune system processes to reduce damage causing inflammation. They do, however, come with various risks and contraindications. Here are a few to keep in mind when considering medications with your health provider.
How they work: Aminosalicylates (5-ASA) reduce inflammatory processes in the body and protect cells from damage. They help promote mucosal healing in the colon and may offer colon cancer protective properties.
Use in IBD: Aminosalicylates are used for mild to moderate UC; some benefits are found in post-operative CD. Recommendations are made on a case-by-case basis for inducing and maintaining remission.
Medication form: oral capsule, rectal suppository
Safety profile: Aminosalicylates have been used as first-line therapy for decades.
Side effects: headache, nausea, abdominal pain, loss of appetite, vomiting, rash, and fever. Sulfasalazine can cause a decrease in sperm production in men. Mesalamine carries a small risk of developing pancreatitis.
Contraindications: Aminosalicylate medications are generally contraindicated if you have a known kidney problem, but your provider may choose to prescribe them and monitor your kidney function. Sulfasalazine is contraindicated if you have a sulfa drug allergy. (Source, Source)
Medication Group: Corticosteroids
Examples: prednisone, budesonide, hydrocortisone
How they work: Corticosteroids are medications modeled after glucocorticoids, steroid hormones produced naturally by the adrenal glands. Glucocorticoids are involved in stress functions in the body, such as dampening immune responses. Corticosteroids are considered both anti-inflammatory and immunosuppressive drugs.
Use in IBD: Corticosteroids are used to induce remission in moderate to severe IBD, but rarely to maintain recovery due to their side effects with long-term use. They are not effective for 20%–30% of people with IBD, but most people taking them will notice an improvement in IBD symptoms.
Side effects: Corticosteroids increase the risk of serious infections that may require hospitalization and intravenous antibiotics, as well as opportunistic infections from microbes that would not ordinarily cause infection. This risk is increased when they are combined with other immunosuppressive medications. Other side effects include increased blood sugar and risk of diabetes, increased blood pressure, acne, weight gain, insomnia, mood swings, and osteoporosis. Corticosteroids reduce the production of certain hormones such as cortisol, adrenaline, and aldosterone, which are important for stress regulation.
Corticosteroids are typically recommended for short-term use. Because they have immunosuppressive effects, long-term use can increase your risk of infections and cancer.
Contraindications: hypersensitivity (allergic) reactions, osteoporosis, systemic fungal infections, uncontrolled high blood sugar or diabetes, uncontrolled blood pressure, joint infection, and chicken pox infection. Live vaccines are contraindicated while you are taking corticosteroids. (Source, Source)
How they work: Biologic agents are medications that are based on or isolated from natural sources. Biologic medications work by controlling inflammation processes. They can block activation of inflammation-causing cells (anti-TNF agents) or regulate the body’s response to inflammation cells (interleukin cell receptor antagonists).
Use in IBD: Biologic agents are used in moderate to severe IBD when there is a minimal response to aminosalicylates or other first-line therapy. Biologics can potentially induce and maintain disease recovery.
Medication form: Under the skin (subcutaneous) injection; often biweekly for typically no longer than 1 year
Side effects: Common side effects of biologic agents include GI disturbances and hypersensitivity reactions. Due to the immunosuppressive effect of biologic agents, they carry the risk of developing severe infections, a risk that increases if you are also taking corticosteroids.
Some less common but serious risks are increased risk of developing demyelinating neurological disease (where the protective cover of your nerves are damaged), autoantibody production (autoimmune reaction to the medication), worsening heart failure, and psoriasis.
Contraindications: Smoking reduces the efficacy of anti-TNF agents. Some biologic medications are not recommended for children or older adults. Safety during pregnancy also varies by drug and must be taken into consideration if you are pregnant or considering pregnancy.
Cost can be a barrier for the use of biologics. A less expensive class of medications called biosimilars (e.g., ustekinumab, vedolizumab) can offer some of the same benefits and risks. (Source, Source, Source, Source)
How they work: Immunomodulators influence specific immune system actions to control inflammation. Their actions are specific and vary by medication.
Use in IBD: Immunomodulators are used in moderate to severe IBD. Cyclosporine is used as a “rescue agent” for hospitalized patients with severe IBD to avoid partial or total colon removal (colectomy).
Medication form: oral pills or capsules
Side effects: Minor side effects of immunomodulators include nausea, vomiting, flu-like illness, and viral infections. All immunomodulators increase the risk of severe and opportunistic infections.
Possible thiopurine complications include risk of pancreatitis, cholestasis (reduced flow of bile from the liver), and myelosuppression (decrease in bone marrow activity leading to a decrease in blood cell production). Thiopurine medications increase the risk of lymphoma, especially if you carry the Epstein–Barr virus, although it’s unclear whether this risk is related to medication or to disease processes. Ongoing treatment with thiopurine medications increases your risk of non-melanoma skin cancers, so wear sun protection and get regular skin examinations when taking these medications.
Possible methotrexate complications include folic acid deficiency, pneumonia, myelosuppression, and liver injury. You may be advised to supplement with folic acid when taking methotrexate.
Contraindications: Methotrexate is contraindicated if you are pregnant or considering becoming pregnant.
Due to an increased risk of pneumonia, you may be advised to consider immunization against pneumococcus before starting these medications. (Source, Source, Source, Source)
Do Antibiotics Help Inflammatory Bowel Disease?
Antibiotic treatments are for infections resulting from progressive IBD, such as abscesses or fistulas in CD. They also treat infections that are due to IBD medications’ side effects.
Antibiotics interfere with the production of bacteria in the body and kill both harmful and beneficial microbes. Some antibiotics have a broad spectrum of action, and some target the digestive tract.
Chronic use of antibiotics causes changes in bacterial balance in the digestive tract, promoting opportunistic bacteria that become more difficult to eradicate. Frequent use of antibiotics can also promote the development of antibiotic-resistant bacteria (superbugs), which can cause severe infections.
Antibiotics are used when the benefit of taking them (to eradicate a bacterial infection making you sick) outweighs the risks (further microbial disturbances, increasing risk of antibiotic resistance, and more serious infections). When needed, opting for narrow or targeted rather than broad-spectrum antibiotics can decrease the risk of superbug infection.
What Are Medication Interactions?
Medication interactions are common when taking different classes of drugs or supplements. Interactions can affect a medication’s effectiveness or toxicity.
If you are concerned about side effects or contraindications of any prescribed medication, it is important to check medication labels and consult your provider before starting or discontinuing any medication.
What Is Pharmacogenomics and How Can It Help?
Pharmacogenomics is the study of how a person’s inherited genes affect the metabolism and effects of medications. Testing for individual genetic differences in drug metabolism can be helpful in predicting side effects.
For example, thiopurines are compounds in immunomodulatory medications that deactivate inflammatory T-cell function when taken in small doses. In larger doses, thiopurines can have a toxic effect. Genetic differences in specific enzymes to break down thiopurines have been connected to low white blood cell count (leukopenia) and increased risk of infections.
Information gained from pharmacogenomics can be important for individualized therapeutic doses and treatment options. Pharmacogenomics is a current field of study and will likely guide many medication decisions in the future.
If you are concerned about genetic differences that might increase your risk of adverse effects from medication, check in with your provider. (Source, Source)
How Will I Know if a Medication Is Working?
The effectiveness of medical therapies for IBD can be checked by monitoring at least 2 inflammation biomarkers. These are tests your medical provider would order before, during, or after treatment.
Serum C reactive protein (CRP) is a systemic (body-wide) indicator of inflammation burden. It relates to an inflammatory immune cell called Interleukin 6, which is the target of some anti-inflammatory medications for IBD. While CRP is not specific to the gastrointestinal system, it can provide information about inflammation progression and response to treatment.
Fecal calprotectin (FC) is a marker of inflammation specific to the gastrointestinal tract. Increased FC is associated with the severity and progression of IBD and may help monitor the effectiveness of treatment. (Source)
Besides monitoring lab work, medication effectiveness is monitored by reports of any side effects you might have. Be sure to mention any new symptoms to your health care provider.
How Do I Manage an IBD Flare?
Including a Whole Person Approach
As with any autoimmune or inflammatory health condition, management involves more than medication. Addressing other parts of your life can also help prevent and manage flares and support maintenance of remission. WellTheory’s Ultimate Guide to Lifestyle Changes for Autoimmune Health will help you understand how lifestyle changes can transform your health.
Food and environmental triggers are common in autoimmune and inflammatory conditions and vary from person to person. Identifying your triggers can support your recovery and maintenance treatment for IBD.
Food choices can also support shifting inflammation states in your body. Correcting nutritional deficiencies and understanding your risk for deficiencies can also support your recovery. For example, vitamin D deficiency is common in those with IBD and plays a significant role in recovery. (Source, Source, Source)
Phosphatidylcholine, a nutrient usually abundant in the colon’s mucosal layer and thought to have protective benefits, is depleted for those with UC and CD with colon involvement. Supplemental phosphatidylcholine could have a supportive role in decreasing inflammation and rebuilding a protective mucosa layer. (Source)
The Bottom Line on Inflammatory Bowel Disease Medications
Inflammatory bowel disease medications target the immune system to decrease inflammation and can help reduce damage to your digestive tract. The proper medication(s) for you depends on the level of inflammation present, your genes, and the risk of medication complications. Medication is not your only option to support IBD recovery and maintenance, though; nutrition and lifestyle are powerful influences on symptom triggers and overall health. Small lifestyle changes can be safely incorporated into any therapy protocol and can help improve your quality of life.