Understanding IBD Medications and Side Effects


Medication information is up to date at the time of printing. Due to rapid advances and new findings, there may be changes to this information over time. You should always check with your doctor to get the most current information.

If you or someone you know has just been diagnosed with Crohn’s disease or ulcerative colitis, you may feel a bit overwhelmed by the news. In fact, you may not have even heard of these illnesses before. But now that you have, you will want to learn as much as possible about them—including which medications can help control the diseases. That is the purpose of this brochure.

About Crohn’s disease and ulcerative colitis

Crohn’s disease and ulcerative colitis belong to a group of conditions known as inflammatory bowel diseases, or IBD. These disorders affect the gastrointestinal (GI) tract, the area of the body where digestion takes place. As the name implies, the diseases cause inflammation of the intestine. When a part of the body is inflamed, it becomes red and swollen. Sores, or ulcers, may also form within the walls of the intestine. The ongoing inflammation leads to symptoms that may already be familiar to you: abdominal pain, cramping, diarrhea, rectal bleeding, and fatigue. For some people, symptoms are not just restricted to the GI tract. They may experience signs of IBD in other parts of the body, such as the eyes, joints, skin, bones, kidney, and liver. These are referred to as extraintestinal manifestations of IBD, because they occur outside of the intestine.

Although Crohn’s disease and ulcerative colitis share a lot of symptoms, they do have some marked differences. While inflammation related to Crohn’s disease may involve any part of the GI tract from the mouth to the anus (including the esophagus, stomach, small intestine, and large intestine), ulcerative colitis is limited to just the large intestine (including the colon and rectum). Another distinguishing feature of ulcerative colitis is that it starts in the rectum and extends from there in a continuous line of inflammation. In contrast, Crohn’s disease may appear in “patches,” affecting some areas of the GI tract while leaving other sections in between completely untouched. These are known as “skip” areas. These differences are important for deciding whether inflammation of the intestinal tract is from Crohn’s disease or ulcerative colitis.

Although you may have never heard of these diseases, approximately 1.4 million American adults and children suffer from Crohn’s disease or ulcerative colitis. Most people develop these diseases between the ages of 15 and 35. The number of newly diagnosed people has exploded over the last 50 years. The exact reasons for this increase are unknown. To date, there is no known cause of or cure for Crohn’s disease or ulcerative colitis, and that’s what makes the Crohn’s & Colitis Foundation of America’s (CCFA) research so critical. CCFA has pioneered the field of research into these difficult digestive diseases for nearly a half-century. Some of our major projects have included human genome (study of genes associated with IBD), microbiome (study of bacterial species), and genetic research.

Treatment

To date, there is no known cause of or cure for IBD, but fortunately there are many effective treatments to help control these diseases.

The three main goals of treatments for IBD are:

  • Achieving remission (defined as the absence of symptoms).
  • Maintaining remission (defined as preventing flare-ups of disease).
  • Improving quality of life (defined personally).

These goals may be achieved either with a combination of over-the-counter and prescription medications, or surgery depending on each individual case. (For more on surgery, visit www.ccfa.org). When considering medication options, you should remember the following key points:

  • Symptoms of these long-term diseases may range from mild to severe and may include, but are not limited to, diarrhea, abdominal cramping, nausea, pain, rectal bleeding, and fever.
  • People will go through periods in which the illness is active and is causing symptoms. Such periods are known as flares. These episodes are usually followed by times of remission. Remission occurs when symptoms either
  • disappear completely or lessen considerably and good health returns. These disease-free periods can last months or even years.

Because each person with IBD is different, the treatment used to control his or her illness is unique, as well. There is no “one-size-fits-all” approach. Doctors will customize treatment to the individual’s needs based on the type and severity of symptoms. It may be given in different dosages, formulations, and for different lengths of time.

  • Medications can be given in oral form (by mouth), intravenously (through a vein), or subcutaneous (by injection under the skin). Topical therapies are administered rectally, as suppositories, enemas, creams, and ointments.
  • It is important to keep in mind that a person’s therapeutic needs may change over time. What works at one point during the illness may not be effective during another stage. It is important for the patient and doctor to discuss thoroughly which course of therapy is best—bearing in mind that a combination of therapies may be the optimal treatment plan.

Over-the-Counter (OTC) Medications 

Prescription medications reduce intestinal inflammation and form the core of IBD treatment. Even so, these important prescription medications may not eliminate all of your symptoms. Naturally, you may want to take over-the-counter medications in an effort to feel better. Before doing so, speak with your doctor, or other healthcare professional, as sometimes these symptoms may indicate a worsening of the inflammation that may require either hospitalization or a change in your prescription IBD medication.

Other times these symptoms do not reflect a worsening of the condition and can be treated with over-the-counter medications. Your doctor may recommend loperamide (Imodium®) to relieve diarrhea, or anti-gas products for bloating. To reduce joint pain and fever, your doctor may recommend acetaminophen (Tylenol®) or non-steroidal anti-inflammatory drugs (NSAID)—such as aspirin, ibuprofen (Advil®, Motrin®), or naproxen (Aleve®). NSAIDs will work to alleviate joint symptoms but can irritate the small intestine or colon, thus promoting inflammation, so these should be used with great care. Make sure that you follow instructions with all OTC products, but again, speak with your healthcare professional first before you take any of these medications.

Prescription Medications

Some medications used to treat Crohn’s disease and ulcerative colitis have been around for years. Others are more recent breakthroughs. The most commonly prescribed medications fall into five basic categories:

  • Aminosalicylates: These include aspirin-like compounds that contain 5-aminosalicylic acid (5-ASA), such as sulfasalazine, balsalazide, mesalamine, and olsalazine. These drugs, which can be given either orally or rectally, do not suppress the immune system but decrease inflammation at the wall of the intestine itself, and help heal both in the short- and long-term. They are effective in treating mild-to-moderate episodes of IBD. They also are useful in preventing relapses (return of symptoms).
  • Corticosteroids: These medications, which include prednisone, prednisolone, and budesonide, affect the body’s ability to begin and maintain an inflammatory process. In addition, they work to keep the immune system in check. Prednisone and prednisolone are used for people with moderate-to-severe Crohn’s disease and ulcerative colitis. Budesonide is used for people with mild to moderate ileal Crohn’s disease, and right-sided colon Crohn’s disease. They can be administered orally, rectally, or intravenously. Effective for short-term control of acute episodes (flares), they are not recommended for long-term or maintenance use because of their side effects. If you cannot discontinue steroids without suffering a relapse of symptoms, your doctor may add some other medications to help manage your disease. It is important not to suddenly stop taking this medication.
  • Immunomodulators: These include azathioprine, 6-mercaptopurine (6-MP), methotrexate, and cyclosporine. This class of medications modifies the body’s immune system so that it cannot cause ongoing inflammation. Usually given orally (methotrexate is injectable), immunomodulators are typically used in people for whom aminosalicylates and corticosteroids haven’t been effective, or have been only partially effective. They may be useful in reducing or eliminating reliance on corticosteroids. They also may be effective in maintaining remission in people who haven’t responded to other medications given for this purpose. Immunomodulators may take up to three months to begin working.
  • Biologic therapies: These therapies are genetically engineered to target very specific molecules involved in the inflammatory process. The newest class of therapy to be used in IBD, these include adalimumab, certolizumab pegol, golimumab, infliximab, and natalizumab. These are not drugs, but proteins (antibodies) that target the action of certain other proteins that cause inflammation. These medications are indicated for people with moderately to severely active disease who haven’t responded well to conventional therapy. They also are effective for reducing fistulas. (Fistulas, which may occur with Crohn’s disease, are small tunnels connecting one loop of intestine to another or two organs in the body that are usually not connected.) Biologics may be an effective strategy for reducing steroid use, as well as for maintaining remission.
  • Antibiotics: Metronidazole, ciprofloxacin, and other antibiotics may be used when infections— such as an abscess—occur. They treat Crohn’s, colitis and perianal Crohn’s disease. They are also used for post-surgical problems such as pouchitis.

Off-Label

Sometimes doctors will prescribe medications that the Food & Drug Administration (FDA) has not specifically approved for the treatment of Crohn’s or colitis. Nonetheless, these medications have been shown to be very effective in reducing symptoms. Prescribing medications for other than FDA-approved conditions is known as “off-label” use. Your healthcare provider may have to obtain prior approval from insurance companies before prescribing a medication for off-label use. Patients should be aware that they or their doctor might need to make a special appeal to get third-party insurance payment for off-label medication.

The use of substances found in nature, such as herbs, foods, and vitamins, is considered biologically-based practice. Unlike pharmaceutical products, natural remedies are not regulated by the FDA.

Pediatric IBD Patients

Customizing treatment for the individual with IBD is critical, but it is especially important when that patient is a child or teenager. Most pediatric treatment choices were developed after initial research on adults. As a result, drug dosages for a child must be carefully tailored to suit their age, size, and weight—in addition to existing symptoms, location of inflammation, and previous response to treatment.

The same medications that are used to treat adults with IBD are also used for children. Still, there are some special considerations in treatment because children and teenagers are going through a period of physical and emotional growth and development. Here are some of the recommendations for the various medication categories:

  • Aminosalicylates: These aspirin-like compounds that contain 5-aminosalicylic acid (5-ASA) are generally the first step in therapy for children with mild-to-moderate ulcerative colitis or Crohn’s disease. Mesalamine and olsalazine have fewer side effects than sulfasalazine. The drugs can be given either orally or rectally. The number of pills may be as many as 10 to 16 per day, which may be difficult with a child’s school schedule. Also, some children have trouble swallowing pills. In cases where swallowing capsules is a concern, your child’s doctor may advise that specific capsules be opened and the contents mixed with food.
  • Corticosteroids: When a child has not responded to treatment with 5-ASA, then oral corticosteroids may be prescribed on an outpatient basis. For more severe cases, intravenous corticosteroids may be used—necessitating a hospital stay. Once remission is achieved, then corticosteroid dosage is tapered gradually. The goal is to discontinue these medications as quickly as possible and thereby minimize side effects, which may include facial swelling, excessive weight gain, hair growth, and acne. Long-term steroid use in children can also lead to growth problems and weakened bones (osteoporosis). To minimize the chance of osteoporosis, adequate calcium and vitamin D intake is essential.
  • Immunomodulators: Both azathioprine and 6-mercaptopurine (6-MP) are widely prescribed for children with Crohn’s disease and ulcerative colitis who do not respond to standard medications. They may minimize symptoms and enhance growth. Treatment with 6-MP has been shown to work well for controlling active disease in children, as well as reducing or eliminating dependency on corticosteroids. They also may be effective in maintaining remission in people who haven’t responded to other medications given for this purpose. Methotrexate is another immunomodulator with similar advantages in limiting corticosteroid use that is increasingly being used in children and adolescents with Crohn’s disease, with somewhat less success so far in ulcerative colitis. All patients on immunomodulators need to be monitored closely for side effects, which include bone marrow problems as well as irritation of the liver or pancreas. 
  • Biologic therapies: Infliximab was the first biologic therapy to be FDA-approved for Crohn’s disease in children, and is now also commonly used to treat ulcerative colitis. Infliximab is usually reserved to treat more advanced or aggressive disease. Other biologic therapies are being tested in children, and are currently used in special situations.
  • Antibiotics: Metronidazole is used in children and teenagers with perianal Crohn’s disease. It may also be used as an alternative treatment to 5-ASA or steroids for Crohn’s or colitis. Another antibiotic option is ciprofloxacin, which has been shown to be effective in adults with colitis and inflammatory changes around the anus, including fistulas and abscesses in Crohn’s disease. The use of ciprofloxacin and other drugs in the same class, called fluorquinolones, has been associated with an increased risk of tendonitis and joint discomfort or pain. Its use in children has been controversial in the past, although studies have not demonstrated any increased risk of complications in children compared to adults.

Pregnancy and Male Fertility

If you are considering becoming pregnant, it is recommend-ed to try to have your IBD in remission before you do so. Recent studies have shown that women do better during pregnancy if their disease is not active at the time of conception. Active disease requires medication, and most doctors prefer that their patients restrict medication during pregnancy. Still, most experts agree that the major threat to the pregnancy seems to come from the active disease itself, rather than the medication.

If you are pregnant and have IBD symptoms, your doctor will advise you as to which of the medications mentioned previously are safe to take. The FDA ranking system for drug safety during pregnancy categorizes all medications from “A” to “D” (safest to least safe), in addition to an extra category, “X.”

  • Category A: Drugs have been tested and found to be safe for use in pregnancy during the first trimester.
  • Category B: Used in pregnancy and does not appear to cause birth defects or other problems.
  • Category C: Drugs that have warnings and are more likely to cause a problem for mother or fetus.
  • Category D: Drugs that have clear health risks, but benefits may outweigh the risk.
  • Category X: Drugs that cause birth defects and should not be used during pregnancy.

Drugs that fall into this last category have been shown to cause birth defects and should never be taken during pregnancy. Please note: Although the rating system provides valuable information, it will no longer be used for new drug therapies, under a March 2008 policy change by the FDA. However, some healthcare professionals are continuing to use this helpful data for existing drug therapies. Information on all known pregnancy and nursing experience will soon appear in the prescribing insert of any medication.

Because pregnancy is such a personal matter and there are so many factors that go into how a pregnancy may turn out, the choice of what medicines to take before and during pregnancy should be discussed with the healthcare provider treating your disease, as well as your obstetrician.

While most of the recommendations regarding medication use and pregnancy focus on women, there are some for men as well. For three months before conception, men should also avoid taking the drug methotrexate. Because the medication sulfasalazine decreases sperm count and therefore may cause infertility, a man taking this drug should switch to another 5-ASA compound (with his doctor’s approval). Discuss all medications with your doctor.

Making the most of your treatment

Crohn’s disease and ulcerative colitis are long-term diseases. This means that people with these conditions may need to take medication indefinitely. While not every person with IBD will be on medication all of the time, most people will require therapy most of the time.

For many individuals—particularly children and teenagers—this may seem like a major concern, especially when some of those medications produce unwanted side effects. If you are experiencing unpleasant side effects or interactions with other drugs, don’t stop taking your prescribed medication. Speak with your doctor and ask about possible adjustments that might reduce those effects.

Even when there are no side effects, or just minimal ones, it may still seem like a nuisance to be on a steady regimen of medication. Seek support from your healthcare provider. Remember, though, that taking maintenance medication can significantly reduce the risk of flares in both Crohn’s disease and ulcerative colitis. In between flares, most people feel quite well and free of symptoms.

Tips to Help You Manage Your Medications:

  • Taking medication correctly means more than just taking the right amount at the right time. Talk to your doctor or pharmacist and learn as much as possible about the medications you take and how they may affect you.
  • Take medications as directed. Remember, more is not necessarily better.
  • Some medications require close monitoring for side effects. Don’t forget to complete blood work and follow-up visits as requested by your provider.
  • Read drug labels carefully. If the print on the container is difficult to read, ask your pharmacist if it can be made larger.
  • Use the same pharmacy every time you get your prescription filled. Pharmacies can help you keep track of what you are taking.
  • Don’t take any medications that have expired.
  • Don’t take anyone else’s medications or share yours with others.
  • Tell your doctor or pharmacist about all medicines you take, including OTC, vitamins, and herbs.
  • Don’t forget to take your medications with you when you travel or will be away from home. Before you leave, make sure you have plenty in case of delays.

Above all, do not stop taking your medications without your doctor’s approval even if you feel you cannot afford them. It is important that you take medications as prescribed, as some cannot be safely stopped abruptly. If the cost of treatment presents a problem for you, that is still not a reason to cut back or discontinue it. A number of patient assistance programs can help. Contact the Crohn’s & Colitis Foundation of America (www.ccfa.org) for more information.

What to Ask Your Healthcare Provider About Your Medications

It is only natural that you will have some concerns about the treatment that you (or your child) will be receiving for IBD. What should you ask your doctor? What do you need to know about your treatment or your child’s treatment? Following are some of the questions you may want to ask:

  • Why is this medication necessary?
  • How long will I need to take this medication?
  • How does this medication work?
  • Can I take vitamins, minerals, herbs, or other supplements while using the medication?
  • Can I take over-the-counter (OTC) medications for joint pain, diarrhea, or abdominal pain?
  • What kind of side effects might I experience? Which are cause for alarm, and what should I do if these occur?
  • Which OTC products would you recommend for me to take if I have pain or other symptoms?
  • What kind of interactions does this IBD medication have with other medications I may be taking for other conditions?
  • What should I do if I miss a dose?
  • What should I do if I have a negative reaction immediately after taking my medication?
  • Is it safe to drink alcoholic beverages while on this medication?
  • What should I do if I can’t afford my medication?

Remember to Tell the Doctor

Before starting new medications, it is important for you to tell your doctor and other healthcare providers (including dentists or emergency room staff) about other medications you may be taking. Tell them whether you:

  • Have taken this drug before (even if there was no unusual reaction).
  • Have had an unusual or allergic reaction to this drug, or other medications.
  • Have or have had any other medical conditions.
  • Take any other medication or drugs (prescription or over-the-counter).
  • Take any vitamins, minerals, herbs, or other supplements.

Participation in clinical trials

Researchers working in laboratories all over the world are devoted to the scientific investigation of Crohn’s disease and ulcerative colitis in the hope of finding a cure. That is good news when it comes to the development of new therapies for these conditions. New discoveries over the past decade have led to huge strides in the fields of immunology, the study of the body’s immune defense system; microbiology, the study of microscopic organisms with the power to cause disease; and genetics, the study of how various tendencies and traits—including diseases—are passed on from one generation to another.

With new information being amassed all the time, there is good reason to be hopeful about future treatment for IBD. While we all wish for better treatments today, we need to understand that it takes a long time for a promising development in the laboratory to become a drug ready for consumer use. In fact, the process of getting a drug to market, from first testing to final approval by the Food & Drug Administration (FDA), sometimes may take as long as 10 years.

Before a new drug or a new type of treatment is approved, it must go through a series of clinical trials. Clinical trials are well-organized studies that evaluate the treatment’s efficacy and safety. Most clinical trials are classified into one of three phases:

  • Phase I trials evaluate how a new drug should be given (by mouth, injected into the blood, or injected into the muscle), how often, and what doses are safe to use.
  • Phase II trials also test the safety of the drug, as well as evaluate how well the new drug works. Finally,
  • Phase III trials test how well the new drug works. Trial participants are divided into groups where one receives the medication and a “control” group receives a placebo (no chemical properties). So, while it is possible that you’ll get the benefit of the new therapy, it is also possible that you will not receive the medication.

Patients often find participation in a clinical trial a rewarding experience. Anyone can participate as long as they meet the criteria for that particular trial. Those criteria may include type of symptoms, location or stage of disease, and age. Your healthcare provider may recommend a trial or you can find out about them yourself from CCFA at http://www.ccfa.org/trials/ or other sources including http://www.clinicaltrials.gov/. All clinical trials, no matter how big or small, have to be registered with this clinical trials Web site.

Should you participate in a clinical trial of a new drug for Crohn’s disease or ulcerative colitis? To make that decision, you need to be fully informed about that trial and the drug that is being tested. All clinical trials have both benefits and risks associated with them. The advances in current IBD treatment are possible only because people before you offered to participate in clinical trials.

Tools and resources

You and your healthcare provider share one important goal: to get your IBD under control and keep it that way. This is also known as achieving and maintaining remission. One of the best ways to accomplish that is by carefully following the medication regimen your doctor has prescribed for you. To help you, we have provided a medication log to carefully track your treatment and care over time. To use the log, fill in the medication information under each category. You may want to leave blank lines under each medication to enable you to record any changes—such as which dosage, times taken, symptoms, or side effects—and additional comments or special directions. We suggest you keep it somewhere handy so you can access it easily. The log also serves as a convenient reference for when you speak with your healthcare providers. Also included in this brochure are medication profiles. The profiles include information about commonly used IBD medications.

This list does not contain all available information about the risks, benefits, and additional warnings for each medication listed. Please speak with your healthcare provider for more detailed information. This information is not intended to replace medical advice from your doctor or other healthcare provider.

Improving quality of life

CCFA has established a range of educational brochures, fact sheets, and programs designed to increase awareness about these digestive diseases.

We know living with Crohn’s or colitis can be difficult, but the right resources and support can make day-to-day living more comfortable. That’s why CCFA has developed a comprehensive, free online community (www.ccfacommunity.org) to provide the support individuals need in managing their condition. Support groups are also available in many locations. Find groups in your area at: www.ccfa.org/chapters, or call 1-888-694-8872.

We recognize the importance of distributing unbiased, accurate, and authoritative information in order to provide education of the finest quality. One avenue used to accomplish this is the Information Resource Center (IRC). Through a toll-free number (1-888-694-8872), e-mail, or live chat on our Web site (www.ccfa.org), Master’s degree level health education professionals answer questions and direct people to resources important to their quality of life. The IRC has truly become an important lifeline for patients, families, friends, healthcare professionals, and the media.

Generic Name: Adalimumab

Brand Name(s): Humira®

Drug class: Biologics

FDA Pregnancy Category: B

How taken: Injection under the skin (subcutaneous)

Used For: Moderate to severe Crohn’s disease

Medication indication: Reduces signs and symptoms and induces and maintains clinical remission in adult patients with moderately to severely active Crohn’s disease who have had an inadequate response to conventional therapy. Reduces signs and symptoms and induces clinical remission in patients who have lost response to or are intolerant to infliximab.

Most common side effects: Injection site reactions such as redness, rash, swelling, itching, pain, or bruising; upper respiratory infections (including sinus infections); headaches, rash, nausea.

Other: Biologics may reduce the body’s ability to fight other infections. There have been reports of serious infections associated with adalimumab, including tuberculosis (TB) and sepsis (a life-threatening blood infection). On rare occasions certain types of cancer, including lymphoma, have been reported.

Generic Name: Azathioprine

Brand Name(s): Azasan®, Imuran®

Drug class: Immunomodulators

FDA Pregnancy Category: D

How taken: Oral, not given by intravenous (IV) for IBD

Used For: Ulcerative colitis and Crohn’s disease

Medication indication: Off-label use for the management of moderate and active inflammatory bowel disease to reduce signs and symptoms.

Most common side effects: Upset stomach, vomiting, diarrhea, muscle aches.

Other: Periodic blood work is necessary when taking Imuran to monitor the liver and blood counts. Infection, a small risk of lymphoma, and a small risk of pancreatitis is noted.

Generic Name: Balsalazide

Brand Name(s): Colazal®

Drug class: Aminosalicylates (5-ASA)

FDA Pregnancy Category: B

How taken: Oral

Used For: Mild to moderate ulcerative colitis

Medication indication: Used to treat the signs and symptoms of mild to moderately active ulcerative colitis in patients five years of age and older. Also, off-label use for treatment of Crohn’s disease.

Most common side effects: Headaches, abdominal pain, diarrhea, nausea, vomiting, respiratory infection, and arthralgia.

Other: Avoid Colazal® if you are allergic to medicines containing salicylates, such as aspirin, or mesalamine (Rowasa®, Asacol®, Pentasa®, Canasa®, Lialda™, and Apriso™).

Generic Name: Budesonide

Brand Name(s): Entocort® EC

Drug class: Corticosteroids

FDA Pregnancy Category: C

How taken: Oral

Used For: Mild to moderate Crohn’s disease

Medication indication: Used for the treatment of mild to moderate active Crohn’s disease involving the ileum and/or the ascending colon.

Most common side effects: Headache, respiratory infection, nausea, and symptoms of hypercorticism (too much steroids in your body). These symptoms include an increase in the size of the face and neck, acne, and bruising.

Other: Entocort® EC is a nonsystemic corticosteroid, which means it is released primarily in the gastrointestinal (GI) tract, therefore causing fewer side effects.

Avoid drinking grapefruit juice regularly as it can increase the amount of Entocort® EC in your body.

Generic Name: Certolizumab pegol

Brand Name(s): Cimzia®

Drug class: Biologics

FDA Pregnancy Category: B

How taken: Injection under the skin (subcutaneous)

Used For: Moderate to severe Crohn’s disease

Medication indication: Reduces signs and symptoms, and induces and maintains clinical remission in adult patients with moderately to severely active Crohn’s disease, who have had an inadequate response to conventional therapy.

Most common side effects: Swelling, weight gain, rash, upper respiratory tract infection, urinary tract infection, and joint pain.

Other: Biologics may reduce the body’s ability to fight other infections. Cases of serious infections including tuberculosis (TB) and sepsis (a life threatening blood

infection) have been reported. Lymphoma and other cancers have been reported on rare occasions.

Generic Name: Ciprofloxacin

Brand Name(s): Cipro®, Proquin®

Drug class: Antibiotics

FDA Pregnancy Category: C

How taken: Oral and intravenous (IV)

Used For: Active Crohn’s disease and pouchitis

Medication indication: May help control symptoms of IBD by reducing intestinal bacteria and by directly suppressing the intestine’s immune system. Effective as a long-term therapy for some patients with Crohn’s disease who have fistulas or recurrent abscesses near their anus. Also effective for people who develop pouchitis.

Most common side effects: Nausea, vomiting, stomach pain, indigestion, diarrhea, headache, nervousness, agitation, anxiety, difficulty falling asleep or staying asleep.

Other: Contains fluoroquinolone, an ingredient associated with an increased risk of tendonitis and tendon rupture.

Generic Name: Cyclosporine

Brand Name(s): Gengraf®, Neoral®, Sandimmune®

Drug class: Immunomodulators

FDA Pregnancy Category: C

How taken: Oral and intravenous (IV) Infusion

Used For: Ulcerative colitis

Medication indication: Off-label use for the management of moderate to severe ulcerative colitis.

Most common side effects: Headache; diarrhea; heartburn; gas; increased hair growth; acne; flushing; shaking of a part of your body that you cannot control; burning or tingling in the hands, arms, feet, or legs; muscle or joint pain; cramps.

Other: Avoid drinking grapefruit juice or eating grapefruit, as this can alter drug levels.

Generic Name: Infliximab

Brand Name(s): Remicade®

Drug class: Biologics

FDA Pregnancy Category: B

How taken: Intravenous (IV) Infusion

Used For: Moderate to severe Crohn’s disease and UC

Medication indication: Remicade® is indicated for reducing signs and symptoms, and inducing and maintaining clinical remission in adult and pediatric patients with moderately to severely active disease, who have had an inadequate response to conventional therapy. Remicade is indicated for reducing the number of draining enterocutaneous and rectovaginal fistulas and maintaining fistula closure in adult patients with fistulizing Crohn’s disease. Remicade® is indicated for reducing signs and symptoms, achieving clinical remission and mucosal healing, and eliminating corticosteroid use in patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy.

Most common side effects: Infusion site reactions such as redness, rash, swelling, itching, or bruising; respiratory infections, such as sinus infections and sore throat; headache; coughing; stomach pain; nausea; and back pain.

Other: As with all biologics, infliximab may lower the body’s ability to fight infection. Infections including tuberculosis (TB) and sepsis (a life-threatening blood infection) have been reported. On rare occasions other cancers such as lymphoma have been reported.

Generic Name: Mercaptopurine (6-MP)

Brand Name(s): Purinethol®

Drug class: Immunomodulators

FDA Pregnancy Category: D

How taken: Oral

Used For: Ulcerative colitis and Crohn’s disease

Medication indication: Off-label use for the management of moderate and active inflammatory bowel diseases to reduce signs and symptoms.

Most common side effects: Headache, weakness, or achiness; darkening of the skin; loss of appetite or weight.

Other: Periodic blood work is necessary when taking mercaptopurine to monitor the liver and blood counts. Infection, a small risk of lymphoma, and a small risk of pancreatitis is noted.

Generic Name: Mesalamine

Brand Name(s): Apriso™, Asacol®, Asacol HD®, Canasa®, Lialda™, Pentasa®, Rowasa®

Drug class: Aminosalicylates (5-ASA)

FDA Pregnancy Category: B

How taken: Oral or rectal

Used For: Mild to moderate ulcerative colitis

Medication indication: Mesalamine delayed-release tablets or capsules and extended-release capsules may be used to treat ulcerative colitis that affects any part of the colon. Mesalamine suppositories and enemas should only be used to treat inflammation of the lower part of the colon. It works by stopping the body from producing a certain substance that may cause pain or inflammation.

Most common side effects: Headache; muscle or joint pain, aching, tightness, or stiffness; back pain; nausea; vomiting; heartburn; burping; constipation; gas; dry mouth; sore throat; cough; flu-like symptoms; stuffy head or runny nose; ear pain; anxiety; sweating; acne; slight hair loss.

Generic Name: Methotrexate

Brand Name(s): Rheumatrex®

Drug class: Immunomodulators

FDA Pregnancy Category: X

How taken: Oral or injection under the skin

Used For: Active Crohn’s disease

Medication indication: Off-label use for the management of active Crohn’s disease to reduce signs and symptoms.

Most common side effects: Nausea, hair loss, headache, dizziness, drowsiness, and mouth sores.

Other:

  • Not recommended for individuals with pre-existing liver disease.
  • Known to cause birth defects.
  • It is recommended for patients to stop methotrexate at least three months prior to planned conception.
  • Reduces the absorption of folic acid.

Generic Name: Metronidazole

Brand Name(s): Flagyl®

Drug class: Antibiotics

FDA Pregnancy Category: B

How taken: Oral

Used For: Active Crohn’s disease and pouchitis

Medication indication: Off-label use of metronidazole may help control symptoms of IBD by reducing intestinal bacteria and by directly suppressing the intestine’s immune system. Effective as a long-term therapy for some patients with Crohn’s disease who have fistulas or recurrent abscesses near their anus. Also effective for people who develop pouchitis.

Most common side effects: Nausea, vomiting, loss of appetite, a metallic taste, diarrhea, dizziness, headaches, and discolored urine (dark or reddish brown).

Generic Name: Natalizumab

Brand Name(s): Tysabri®

Drug class: Biologics

FDA Pregnancy Category: C

How taken: Intravenous (IV) infusion

Used For: Moderate to severe Crohn’s disease

Medication indication: Reduces signs and symptoms, and induces and maintains clinical remission in adult patients with moderately to severely active Crohn’s disease who have had an inadequate response to conventional therapy, including inhibitors of TNF-alpha.

Most common side effects: Infections such as in the urinary tract or upper respiratory tract, headache, tiredness, depression, joint pain, diarrhea, and stomach area pain.

Other: Natalizumab increases the risk of progressive multifocal leukoencephalopathy (PML), a rare brain infection. Natalizumab may also cause liver damage and allergic reactions.

Generic Name: Olsalazine

Brand Name(s): Dipentum®

Drug class: Aminosalicylates (5-ASA)

FDA Pregnancy Category: C

How taken: Oral

Used For: Ulcerative colitis

Medication indication: For the maintenance of remission of ulcerative colitis in patients who are intolerant of sulfasalazine.

Most common side effects: Stomach upset, bloating, loss of appetite, blurred vision, headache, pain in joints, and dizziness.

Other: Avoid Dipentum® if you are allergic to medicines containing salicylates, such as aspirin, or mesalamine.

Generic Name: Prednisolone

Brand Name(s): Medrol®, Pediapred Oral Liquid®

Drug class: Corticosteroids

FDA Pregnancy Category: C

How taken: Oral

Used For: Moderate to severe Crohn’s disease and UC

Medication indication: For the management of active Crohn’s disease and ulcerative colitis to reduce signs and symptoms.

Most common side effects: Upset stomach, stomach irritation, vomiting, headache, dizziness, insomnia, restlessness, depression, anxiety, and acne.

Generic Name: Prednisone

Brand Name(s): Deltasone®

Drug class: Corticosteroids

FDA Pregnancy Category: C

How taken: Oral

Used For: Moderate to severe Crohn’s disease and UC

Medication indication: For the management of active Crohn’s disease and ulcerative colitis to reduce signs and symptoms.

Most common side effects: Headache, dizziness, difficulty falling asleep or staying asleep, inappropriate happiness, extreme changes in mood, changes in personality, bulging eyes, and acne.

Generic Name: Sulfasalazine

Brand Name(s): Azulfidine®

Drug class: Aminosalicylates (5-ASA)

FDA Pregnancy Category: B

How taken: Oral

Used For: Ulcerative Colitis

Medication indication: For the treatment of mild to moderate ulcerative colitis, and as adjunctive therapy in severe ulcerative colitis; and for the prolongation

of the remission period between acute attacks of ulcerative colitis. Also, off-label use for treatment of Crohn’s disease.

Most common side effects: Diarrhea, headache, loss of appetite, upset stomach, vomiting, and stomach pain.

Other: Low sperm count and infertility have been observed in men treated with sulfasalazine; however, withdrawal of the drug appears to reverse these effects.

Generic Name: Tacrolimus

Brand Name(s): Prograf®

Drug class: Immunomodulators

FDA Pregnancy Category: C

How taken: Oral and intravenous (IV)

Used For: Moderate to severe Crohn’s disease and ulcerative colitis

Medication indication: Off-label use for the management of active Crohn’s disease and ulcerative colitis to reduce signs and symptoms.

Most common side effects: Headache, hypertension, diarrhea, constipation, nausea, vomiting, heartburn, stomach pain, loss of appetite, difficulty falling asleep or staying asleep, dizziness, weakness, back or joint pain, burning, numbness, pain or tingling in the hands or feet, rash, and itching.

Other: Avoid eating grapefruit or drinking grapefruit juice while taking tacrolimus.

Table I. Pregnancy Drug Safety Chart

Drug

FDA pregnancy category

Recommendations for pregnancy

Recommendations for breast-feeding

Adalimumab

B

Low risk

No human data: probably compatible

Alendronate

C

Limited human data

Safety unknown

Amoxicillin/clavulanic acid

B

Low risk

Probably compatible

Azathioprine/ 6-mercaptopurine

D

Data in IBD, transplant literature suggest low risk

Limited human data: probably compatible

Balsalazide

B

Low risk

No human data: potential diarrhea

Budensonide

C

Low risk in pregnancy: limited human data

Compatible with breast feeding

Certolizumab pegol

B

Limited human data: low risk

No human data: probably compatible

Ciprofloxacin

C

Avoid: potential toxicity to cartilage

Limited human data: probably compatible

Corticosteroids

C

Low risk: possible increased risk of cleft palate, adrenal insufficiency, premature rupture of membranes

Compatible

Cyclosporine

C

Low risk

Limited human data: potential toxicity

Fish oil supplements

---

Low risk: possibly beneficial

No human data

Infliximab

B

Low risk

No human data: probably compatible

Mesalamine

B

Low risk

Limited human data: potential diarrhea

Methotrexate

X

Contraindicated: teratogenic

Contraindicated

Natalizumab

C

Limited human data: likely low risk

No human data

Metronidazole

B

Would avoid, given limited efficacy in IBD and risk of cleft palate

Limited human data: potential toxicity

Olsalazine

C

Low risk

Limited human data: potential diarrhea

Rifaximin

C

Animal teratogen: no human data

No human data: probably compatible

Risedronate

C

Limited human data

Safety unknown

Sulfasalazine

B

Considered low risk; give folate 2 mg daily

Limited human data: potential diarrhea

Tacrolimus

C

Use if mother’s health mandates

Limited human data: potential toxicity

Thalidomide

X

Contraindicated: teratogenic

No human data: potential toxicity

Glossary of terms

  • Abscess: A collection of pus (dead neutrophils) that has accumulated in a cavity formed by the tissue because of an infectious process (usually caused by bacteria or parasites).
  • Adherence: Sticking to a prescribed medical regimen.
  • Aminosalicylates: See page 6.
  • Antibody: An immunoglobulin, (a specialized immune protein), produced because of the introduction of an antigen (foreign substance) into the body.
  • Antibiotics: Drugs that fight infections, such as metronidazole and ciprofloxacin.
  • Anus: Opening at the end of the rectum that allows solid waste to be eliminated.
  • Biologic Therapies: See page 7.
  • Bowel: Another name for the intestine. The small bowel and the large bowel are the small intestine and large intestine, respectively.
  • Chronic: Long-lasting or long-term.
  • Colitis: Inflammation of the large intestine (the colon).
  • Colon: The large intestine.
  • Corticosteroids: See page 6.
  • Crohn’s disease: A chronic inflammatory disease that primarily involves the small and large intestine, but that can affect other parts of the digestive system as well. It is named for Burrill Crohn, the American gastroenterologist who first described the disease in 1932.
  • Diarrhea: Passage of excessively frequent or excessively liquid stools.
  • Extraintestinal complications: Complications that occur outside of the intestine, such as arthritis or skin rashes. In some people, these may actually be the first signs of IBD, appearing even before the bowel symptoms. In others, they may occur right before a flare-up of the disease.
  • FDA: Food & Drug Administration.
  • Fistula: A tunnel that leads from one loop of intestine to another, or that connects the intestine to the bladder, vagina, or skin. Fistulas occur most commonly around the anal area. If this complication arises, you may notice drainage of mucus, pus, or stool from this opening.
  • Flare or flare-up: Presence of inflammation and symptoms.
  • Gastrointestinal: Adjective referring collectively to the stomach and small and large intestines.
  • GI tract: Short for gastrointestinal tract.
  • Immune system: The body’s natural defense system that fights against disease.
  • Immunomodulators: See above.
  • Immunosuppressive: The suppression of the immune system; an agent that reduces the function of the immune system.
  • Inflammation: A response to tissue injury that causes redness, swelling, and pain.
  • Inflammatory bowel diseases (IBD): A term used to refer to a group of disorders—including Crohn’s disease (inflammation in the gastrointestinal tract) and ulcerative colitis (inflammation in the colon).
  • Intestine: The long, tubelike organ in the abdomen that completes the process of digestion. It consists of the small and large intestines.
  • Large intestine: Also known as the colon. Its primary function is to absorb water and get rid of solid waste.
  • NSAIDs: Nonsteroidal anti-inflammatory drugs such as aspirin, ibuprofen, ketoprofen, and naproxen.
  • Off-label: Use of an FDA-approved drug for an indication other than that for which the drug was approved originally.
  • Oral: By mouth.
  • Perianal: Located around the anus, the opening of the rectum, to the outside of the body.
  • Pouchitis: Inflammation of the lining of the internal pouch (formed from the small intestine).
  • Rectal: Having to do with the rectum.
  • Rectum: Lowest portion of the colon.
  • Remission: Periods in which symptoms disappear or decrease and good health returns.
  • Small intestine: Connects to the stomach and large intestine; absorbs nutrients.
  • Subcutaneous: Injected under the skin.
  • Teratogen: An agent or substance that may cause defects in the developing embryo.
  • Teratogenic: Capable of causing birth defects.
  • Toxicity: The degree to which a substance is harmful.
  • Ulcer: A sore on the skin or in the lining of the GI tract.
  • Ulceration: The process or fact of being eroded away, as by an ulcer.
  • Ulcerative colitis: A relatively common disease that causes inflammation of the large intestine (the colon).

This brochure is supported by an unrestricted educational grant from Abbott.



For further information, call the Irwin M. and Suzanne R. Rosenthal IBD Resource Center (IBD Help Center): 888.MY.GUT.PAIN (888.694.8872).

The Crohn’s & Colitis Foundation of America provides information for educational purposes only. We encourage you to review this educational material with your health care professional. The Foundation does not provide medical or other health care opinions or services. The inclusion of another organization’s resources or referral to another organization does not represent an endorsement of a particular individual, group, company or product.

About this resource

By: CCFA
Published: November 30, 2009