IBD Academy: Treatment with 5-ASAs and Corticosteroids

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Understanding the medications used to treat inflammatory bowel disease can help you to be a knowledgable part of your healthcare team. Many individuals with IBD end up taking a whole series of medications before their doctors find the one(s) that work for them. There are four major classes of drugs used to treat IBD: aminosalicylates (5-ASAs), corticosteroids, immunomodulators, and biologics. A few other options, antibiotics, antiemetics, and anti-diarrheals, are used to target associated symptoms, but to not treat IBD itself. This post will cover 5-ASAs, corticosteroids, auxillary drugs, and the different ways that medication can be administered.

Routes of Administration

  • oral tablet or capsule: medication is swallowed whole and absorbed into the body via the digestive tract.
  • orally disintegrating (sublingual) tablet: a dissolvable tablet is placed under the tongue and absorbed through the cheek. ODTs begin to work faster than tablets that are swallowed.
  • suppository: a wax-based form of medication is placed in the rectum to target IBD confined to the rectum (proctitis). Rectal administration applies the drug to the affected tissue while limiting the amount of drug that is present in the body as a whole.
  • rectal foam: medication formulated as a foam is propelled into the rectum to target IBD of the rectum and sigmoid colon (proctosigmoiditis).
  • enema: a liquid suspension of medication is put directly into the rectum. This method is used to target IBD which has spread up through the rectum into the distal colon (distal colitis).
  • subcutaneous (SC) injection: medication in liquid form is injected and absorbed under the skin.
  • intramuscular (IM) injection: medication in liquid form is injected directly into the muscle (usually the upper arm or thigh).
  • intravenous (IV) injection: medication in liquid form is injected through a needle which has been inserted into a vein.
 The small intestine connects the stomach and the colon. It includes the duodenum, jejunum, and ileum. © 2013 Terese Winslow LLC (some rights held by National Institutes of Health).

The small intestine connects the stomach and the colon. It includes the duodenum, jejunum, and ileum. © 2013 Terese Winslow LLC (some rights held by National Institutes of Health).

 The left side of the colon has four sections: the descending colon, the sigmoid colon, the rectum, and the anus. © 2018 Cedars-Sinai.

The left side of the colon has four sections: the descending colon, the sigmoid colon, the rectum, and the anus. © 2018 Cedars-Sinai.

Aminosalicylates (5-ASAs)

  • goal: to reduce inflammation in the lining of the digestive tract.
  • mechanism of action
    • believed to act locally to interfere with the ability of certain white blood cells (lymphocytes and macrophages) to function on the mucosal lining of the intestine. Left unchecked, these WBCs attack the mucosa and damage the tissue.
    • believed to act systemically to inhibit the production of some pro-inflammatory prostagladins, leukotrienes, and cytokines, which are small chemical molecules that circulate in the bloodstream and mediate inflammation.
  • common forms
    • oral: time-release and pH-sensitive properties of each medication determine when are where along the intestinal tract it's absorbed.
      • targets jejunum, ileum and colon: Pentasa (extended release mesalamine)
      • targets ileum and colon: Delzicol and Lialda (mesalamine)
      • targets colon only: Azulfindine (Sulfasalazine), Colazal (balsalizide), Dipendum (olsalazine), Apriso (mesalamine)
    • suppository: Canasa (mesalamine)
    • rectal foam: Salofalk (mesalamine)
    • enema: Rowasa (mesalamine)
  • in ulcerative colitis
    • shown to successfully induce and maintain remission in mild to moderate UC.
  • in Crohn's disease
    • shown to help control mild inflammation.
    • most often must be used in conjunction with other medications in order to achieve remission in these patients.

Corticosteroids

  • goal: to reduce inflammation in the lining of the digestive tract and reduce diarrhea.
  • mechanism of action: act via the glucocorticoid receptor to interfere with cellular production of inflammatory proteins and activate anti-inflammatory proteins. Additionally, they act via sodium pumps in intestinal mucosal cells to increase sodium and water absorption.
  • common forms:
    • oral: prednisone, prednisolone, Entocort (budesonide)
    • suppository: hydrocortisone
    • enema: cortisone
    • rectal form: Uceris (budesonide)
    • IV: Solumedol (methylprednisolone), Decadron (dexamethasone)
  • approximately half of IBD patients treated with steroids will become steroid dependent or steroid resistant
  • cannot be stopped abruptly after extended use (patients must be slowly weaned down on progressively smaller doses) 

AUxillary Drugs

  • goal: target specific symptoms of IBD, but don't address the underlying causes. 
  • antibiotics: reduce a wide range of intestinal bacteria and are believed to directly suppress the intestine's immune system.
    • Cipro (ciprofloxacin): oral and IV
    • Flagyl (metronidazole): oral and IV
    • particularly effective in treating Crohn's patients with fistulas or absesses
    • not very effective in UC patients, with the exception of acute toxic megacolon
    • often used to treat pouchitis in ileoanal pouch (j-pouch) patients
  • antiemetics: target a variety of receptors in the brainstem to inhibit the gut's autonomic nervous system response that causes nausea and vomiting.
    • Zofran (ondansetron): ODT and IV
    • Phenergan (promethazine): oral, IV (central lines only) and IM
    • Reglan (metoclopramide): oral, IV
  • anti-diarrheals: slow peristalsis, the involuntary waves of muscle contractions that propel fecal matter along the digestive tract, allowing more water to be absorbed and the stool to be more compact.
    • Immodium (loperamide)
    • Lomotil (diphenoxylate/atropine)

While we strongly advocate being involved in decisions regarding your treatment, make sure that you only take medications as prescribed by your doctor and under his/her supervision.

Coming up next is IBD Academy: Treatment with Immunomodulators and Biologics.

Sources

  1. J. Le. Drug administration. http://www.merckmanuals.com/home/drugs/administration-and-kinetics-of-drugs/drug-administration
  2. J. Brown,  S. Haines, and I.R. Wildling. Colonic spread of three rectally administered mesalazine (Pentasa) dosage forms in healthy volunteers as assed by gamma scintigraphy. http://onlinelibrary.wiley.com/store/10.1046/j.1365-2036.1997.00193.x/asset/j.1365-2036.1997.00193.x.pdf;jsessionid=6A978D9613B79CD5DD0C507E71443B92.f02t01?v=1&t=jdyvpggv&s=cd915a8aacf5d37dc1f5d19c6727381c06a0326e
  3. Crohn's and Colitis Foundation. Fact Sheet: News from the IBD help center: Aminosalicylates: http://www.crohnscolitisfoundation.org/assets/pdfs/aminosalicylates.pdf
  4. A. Cheifetz and G. Cullen. Patient education: Sulfasalazine and the 5-aminosalicylates (Beyond the Basics). https://www.uptodate.com/contents/sulfasalazine-and-the-5-aminosalicylates-beyond-the-basics
  5. Tulane University School of Medicine: Pharmwiki: 5-aminosalicylates: http://tmedweb.tulane.edu/pharmwiki/doku.php/5-aminosalicylates
  6. S. Hanauer. Review article: aminosalicylates in inflammatory bowel disease. http://onlinelibrary.wiley.com/store/10.1111/j.1365-2036.2004.02048.x/asset/j.1365-2036.2004.02048.x.pdf?v=1&t=je05us9j&s=d32f4d2729b286943d0493bb8c9a28231ffb4f14
  7. P.M. Irving, R.B. Gearry, M.P Sparrow, and P.R. Gibson. Review article: appropriate use of corticosteroids in Crohn's disease. http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2036.2007.03379.x/full
  8. R. Hu for Crohn's and Colitis Foundation of America: An update in inflammatory bowel disease medications. http://online.ccfa.org/site/DocServer/An_Update_in_IBD_Medications.pdf/846926729?docID=31678
  9. Crohn's and Colitis Foundation: Resources: Antibiotics: http://www.crohnscolitisfoundation.org/resources/antibiotics.html?referrer=https://www.google.com/
  10. University of Utah College of Pharmacy: Antiemetics drug class review. http://www.health.utah.gov/pharmacy/ptcommittee/files/Criteria%20Review%20Documents/03.14/Antiemetic%20Drug%20Class%20Review.pdf
  11. Cedars-Sinai: Sigmoid Colectomy: https://www.cedars-sinai.edu/Patients/Health-Conditions/Sigmoid-Colectomy.aspx
  12. National Cancer Institute: Small Intestine Cancer-Patient Version: https://www.cancer.gov/types/small-intestine

 

Kristen Weiss Sanders is a proud ostomate and third generation girl with guts diagnosed with IBD in 2004. She is passionate about patient education and encourages those with chronic illness to be a knowledgable part of their healthcare team. Kristen credits the constant example and support of the strong women in her family for her determination to thrive with Crohn’s disease and use her IBD journey to empower others.

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