Let's Talk About Crohn's Disease Medication
With so many options available and more coming down the pike, you’re bound to find a treatment that works for you. Here's what to know about the latest drug therapies.
Crohn’s medications have come a long way in the last two decades. With the advent of biologics—a breakthrough class of meds made from natural sources—more patients are able to significantly reduce their symptoms and keep it that way. The options can be confusing, though, which is why we’ve created this easy-to-swallow guide to get you up to speed on all the benefits, risks, and side effects. Ready?
Our Pro Panel
We went to some of the nation’s top experts on Crohn's to bring you the most up-to-date information possible.
Jami Kinnucan, M.D.
Gastroenterologist, IBD Specialist, and Assistant Professor of Medicine
University of Michigan School of Medicine
Ann Arbor, MI
Neilanjan Nandi, M.D.
Director of the Inflammatory Bowel Disease Center
Drexel University School of Medicine
Frank I. Scott, M.D.
Gastroenterologist, IBD Specialist, and Assistant Professor of Medicine and Gastroenterology
University of Colorado School of Medicine
Most likely. You won’t necessarily take the same medications, however. The types of meds you need may change over time, as your body and the disease adapt and evolve. Plus, new and better medications are being developed all the time.
Steroids are great for getting flares under control, but they have many serious side effects when used long term, including high blood pressure, osteoporosis, and cataracts. Biologics and immunomodulators are more beneficial and safer for longer term treatment.
That may be an option. Biologics initially targeted moderate to severe symptoms in people who didn’t respond well to other therapies. However, biologics have been so effective that they are starting to be used more and more as first-line treatments. Talk to your doctor about the possibility.
We don’t have any good research supporting the use of medical marijuana for Crohn’s disease, but anecdotally patients have reported that it relieves some of their symptoms. It’s important to understand, however, that medical marijuana should not replace the other medications needed to induce and stay in remission.
What Is Crohn’s Disease Again?
Categorized as an Inflammatory Bowel Disease (IBD), Crohn’s is triggered by the immune system’s white blood cells attacking your body’s healthy tissue in the digestive, a.k.a. gastrointestinal (GI), tract.
This leads to a series of events:
The attack of white blood cells produces inflammation, most commonly in the small or large intestine.
In turn, this leads to ulcers and tissue swelling that limit your body’s ability to process food, absorb nutrition, and eliminate waste.
The result: Abdominal pain, diarrhea, and weight loss.
Of the estimated 3.1 million Americans who have received an IBD diagnosis (which also includes ulcerative colitis and the less common indeterminate colitis and microscopic colitis), about 780,000 have Crohn’s disease, according to the Crohn’s & Colitis Foundation.
It affects men and women equally, and can occur at any age, although it is most common between the ages of 15 and 30, and again in your 50s and 60s.
What Medications Are Available to Treat Crohn’s Disease?
A silver lining if you have Crohn’s: There are more medication possibilities than ever before, including:
Figuring out which ones are best for you is another matter. Because Crohn’s disease manifests itself differently depending on its location in the digestive tract—patches of it can occur anywhere from the mouth to the anus—it’s a unique disease for every person.
Crohn’s can also be unpredictable: Sometimes the disease will be active and you will experience symptoms that range from moderate to severe. This is called a flare. Other times, you will be in remission, when there are little to no symptoms and no disease activity.
All this also means there is no one-size-fits-all standard line of treatment, and whatever approach you choose may change over time as your body and the disease adapt and evolve.
The first meds your doctor prescribes will focus on getting your symptoms under control during a flare. After that, you’ll switch your focus to finding meds that help keep you in remission, ideally for months or even years.
Here’s a tricky thing about Crohn’s meds: Close to half of all patients don’t respond to some of the medications, but doctors have no way of telling who will—or won’t—respond, or why, or to which meds.
So yeah, you’ll be seeing your doctor a lot at first as you try to figure out an effective treatment plan. Also, since a flare could indicate that your meds have stopped working, you’ll likely periodically see your doc to adjust dosage or try a new approach.
There are five classes of Crohn’s disease medications your doctor may prescribe. Let’s take a deeper look at the pros and cons for each of these options.
These 5-aminosalicylic acid (5-ASA) compounds work by inhibiting pathways that produce substances that cause inflammation. These meds are used mostly for treating ulcerative colitis, and some experts question how successful they are in treating Crohn's. They may help with mild cases or as a maintenance treatment to prevent relapses, but are increasingly being passed over for more effective treatment options.
These drugs work best in the colon and won’t help if only your small intestine is affected. The latest research also shows aminosalicylates often need to be used in conjunction with other medications to adequately control inflammation and prevent complications. The two types of 5-ASAs used for Crohn’s disease are:
Azulfidine (sulfasalazine): This med can help get mild to moderate symptoms and inflammation in your large intestine (colon) under control via a delayed release tablet that targets the colon or rectally as an enema or suppository if your disease is in the lower colon. Men may have a temporary drop in sperm count or infertility while taking sulfasalazine, but sperm count should return to normal once the medication is stopped. Patients with sulfa allergies should not take sulfasalazine.
Pentasa (mesalamine): This medication does not contain sulfa, so your doctor may prescribe it early on to treat mild symptoms of Crohn’s disease in the colon if you have a sulfa allergy. Some research suggests high doses of mesalamine can be an effective alternative therapy to induce remission in patients who want to avoid corticosteroids. Mesalamine can be taken three ways:
Orally: This pill is coated or placed in a special capsule to ensure it makes it all the way to the colon. The type of coating, which varies by brand, determines exactly where in the colon the drug is released. Brands include Asacol, Apriso, Delzicol, Lialda, and Pentasa. You’ll take the pill one to three times a day.
Suppository: These suppositories (brand name Canasa) deliver mesalamine directly to the rectum to provide relief from the urgency and frequency of bowel movements. For some patients, a combo of rectal and oral therapies may be most effective. You’ll take this drug one to two times a day.
Enema: Some people are affected with left-side colon inflammation and may benefit from a daily liquid enema (brand name Rowasa), which reaches higher than a suppository. You’ll need to keep the enema in your colon for at least 20 to 40 minutes.
Side Effects and Safety
Aminosalicylates are generally well-tolerated and safe, including during pregnancy and while breastfeeding. Common side effects may include:
loss of appetite
Less commonly, they cause diarrhea. Very rarely they can cause kidney injury, so if you have kidney problems, try a different approach. Sulfasalazine and mesalamine have also rarely been associated with pancreatitis.
Known as steroids for short, these drugs are one of the oldest treatments for Crohn’s disease. They work by suppressing the entire immune system and decreasing inflammation.
When you’re first diagnosed, you’ll likely be given a steroid to get your symptoms under control. After that, you may need steroids during flares to induce remission again. While they are highly effective and fast working, steroids can only be used short term because they have serious side effects.
Steroids are most commonly given orally, but some may be given intravenously or rectally. Oral options include:
A-Methapred, Depo-Medrol, Medrol Dosepak, and Solu-Medrol (methylprednisolone): This steroid may also be given intravenously for severe flares.
Deltasone (prednisone) and Oraped, Prelone, and Pediapred (prednisolone): These common steroids are frequently prescribed for moderate to severe flares.
Entocort EC (budesonide): This newer type of oral steroid may have fewer side effects because it’s rapidly metabolized by the liver. It’s used for mild to moderate flares that involve the ileum (small intestine) or the first part of the large intestine.
Solu-Cortef (hydrocortisone): This form of hydrocortisone can also be given intravenously for severe symptoms.
Topical steroids can be given via the rectum to treat localized inflammation in the lower part of the colon and rectum. These are available as either a bullet-like capsule (suppository) inserted through the anus, or as a liquid or foam in a special applicator (enema).
While these types of applications aren’t exactly fun, they minimize body-wide exposure (known as systemic exposure) to the drugs, meaning you have a lower risk of side effects. Options for suppositories or enemas include:
Anusol (hydrocortisone): As a suppository, hydrocortisone can be very helpful in the short term for inflammation in the anus and rectum, particularly if you have frequent and urgent bowel movements. But long-term use can weaken the all-important muscles in your rectum and anus that basically hold in your poop!
Cortenema and ProctoFoam HC (hydrocortisone): These liquid and foam steroid enemas are used to treat inflammation higher in the rectum that can’t be reached by suppositories.
Side Effects and Safety
Because they suppress the immune system, steroids make you vulnerable to infections, especially in the urinary tract, female reproductive organs, and mouth (a yeast infection called thrush).
Steroids can also impact other parts of the body and cause significant side effects, including:
growth disturbance in children
high blood pressure (hypertension)
high blood sugar levels
increased facial hair
psychosis and other psychiatric symptoms
rounding of the face
weakened bones (osteoporosis)
An important note: Steroids cause the adrenal glands to slow or stop the production of cortisol, a naturally occurring human steroid. As a result, the dose needs to be tapered off slowly to give the adrenal glands time to ramp up cortisol production again.
These medications reduce immune system activity, lowering inflammation in your digestive tract. They are sometimes paired with biologics, and typically help maintain remission in patients who have not responded to other medications or have only responded to steroids.
Immunomoduators are usually given orally. The downside: They can take weeks to three months to start working—a long time when you’re suffering with symptoms. Options include:
Azasan and Imuran (azathioprine): One of the first immunomodulators used for IBD, azathrioprine helps maintain remission in Crohn’s disease. It can take three to six months to kick in, so it’s usually given with a steroid (at first) or biologic.
Purinethol (mercaptopurine or 6-MP): Another early immunomodulator for IBD, this drug is chemically very similar to azathioprine and aims to maintain remission.
Prograf (tacrolimus): Although it’s more effective in treating ulcerative colitis, tacrolimus can be used to treat Crohn’s when steroids don’t work or fistulas develop. It may be used topically for symptoms of the mouth or anus, or intravenously in severe cases.
Rheumatrex (methotrexate): Given as a weekly injection (or sometimes orally), this common Crohn’s treatment blocks cell production, helping to control inflammation. Methotrexate can cause birth defects and should not be taken by either women or men for at least three months prior to conception. Women shouldn’t take it during pregnancy, and regular bloodwork is usually required to ensure adequate blood counts, and to check kidney and liver function when you are taking this drug.
Side Effects and Safety
Each of these medications comes with side effects, including:
burning, numbness, pain or tingling in the hands and feet (tacrolimus)
hair loss (methotrexate)
low white blood cell count, which means you will be more vulnerable to infections
nausea and vomiting
pancreatitis (6-MP, azathioprine)
When you have Crohn’s, you are especially prone to a serious and highly contagious intestinal infection known as Clostridioides difficile (C. diff). Your doctor may prescribe antibiotics if you develop this or other bacterial infections in the GI tract, or if you have complications that require surgery.
The most commonly used antibiotics for Crohn’s disease are Cipro or Proquin (ciproflaxin) and Flagyl (metronidazole). In addition, Vancocin (vancomycin) is frequently used to treat C. diff. Antibiotics are usually taken as a pill or capsule but may also be given intravenously.
Side Effects and Safety
Most people tolerate antibiotics well, but side effects can include:
loss of appetite
The newest class of Crohn’s disease medications is also the most promising. These drugs are called biologics because they’re made from naturally occurring materials that can put the brakes on inflammation-causing proteins.
Initially used for people with moderate to severe symptoms who didn’t respond well to other therapies, biologics are increasingly given as first-line treatments. They offer a definite advantage over other options because they precisely target particular proteins that have been proven to be involved in IBD.
Although they do have side effects, biologics don’t impact the whole body like steroids. You might also be prescribed a biosimilar, which is basically identical to a biologic but significantly cheaper (sort of like the generic version of the drug).
There are three classes of biologics currently available for Crohn’s disease:
1. Anti-Tumor Necrosis Factor Agents
Known as anti-TNF agents for short, these drugs bind to and block a protein called tumor necrosis factor alpha (TNF-alpha) that promotes inflammation.
Anti-TNF medications reduce symptoms while helping the inflamed intestine to heal. They are given by injection or infusion and can take up to eight weeks to work. Anti-TNF agents you may be given include:
Cimzia (certolizumab pegol): This anti-TNF agent can be self-injected to reduce symptoms and maintain remission in moderate to severe Crohn’s disease. Your first three injections will be every two weeks, followed by every four weeks.
Humira (adalimumab): Your doctor may prescribe this med to induce and maintain remission if you have moderate to severe Crohn’s disease. It’s given as a quick injection under the skin of the abdomen or thigh. The first dose is typically four injections, followed by two injections two weeks later, both given in your doctor’s office. After that, you will need one injection every two weeks at home. Amjevita (adalimumab-atto) and Cyltezo (adalimumab-adbm) are biosimilar versions of Humira given in the same dosing pattern.
Remicade (infliximab): The first biologic developed in the late 1990s to treat Crohn’s disease, Remicade is used to reduce symptoms and maintain remission. Your doctor may also prescribe it to treat fistulas. It’s given by IV infusion which takes two to four hours. Initially, you will receive three doses over a six-week period, followed by a dose every eight weeks thereafter. Renflexis (infliximab-abda), Inflectra (infliximab-dyyb), and IXIB (infliximab-qbtx) are biosimilars given in the same dosing pattern.
2. Integrin Receptor Antagonists
This class of biologics block the cells that cause inflammation so they can’t reach the tissues. There are two options currently available to treat Crohn’s disease:
Tysabri (natalizumab): Given as an infusion every four weeks, this drug induces and maintains remission in moderate to severe Crohn's cases. It’s often used if you’ve had an inadequate response or are unable to tolerate other therapies. The drug increases your risk of a severe brain condition known as progressive leukoencephalopathy (PML). Patients most at risk carry the John Cunningham virus; you'll be tested for it before starting Tysabri.
Entyvio (vedolizumab): Entyvio is similar to Tysari, but it targets the gut and has not been shown to enter the brain or increase the risk of PML. It’s also given as an IV infusion. Initially, you will receive three doses over a six-week period, followed by a dose every eight weeks thereafter.
3. Interleukin-12 and 23 Antagonist
This type of biologic targets the interleukin-23 and interleukin-12 proteins, which have been shown to play a key role in inflammation.
Currently, the only medication in this class approved for moderate to severe Crohn’s disease that hasn’t responded to other therapies is called Stelara (ustekinumab). The first dose is an IV infusion based on your body weight, followed by an injection every eight weeks that you can do at home.
Side Effects and Safety
Biologics suppress your immune system, increasing your risk of infection. And dormant infections you may carry, such as tuberculosis or Hepatitis B, may become reactivated when you take a biologic. For these reasons, you’ll need to be tested for both of them, and stay up-to-date on vaccines, including an annual flu shot.
Your doctor should also be aware of other health issues you may have, such as heart failure, hepatitis, and multiple sclerosis, to determine if the benefits of biologics outweigh the risks for you.
Other side effects include:
swelling at site of injection
Rarely, biologics—especially anti-TNF agents—may increase your risk of:
lupus-like reaction that includes rash, joint pain, muscle ache and fever
Some medicine cabinet staples may also be helpful in dealing with your symptoms, including anti-diarrheal and anti-gas meds, as well as Tylenol (acetaminophen) for pain. Always talk to your doctor first about what’s safe.
Avoid nonsteroidal anti-inflammatories (NSAIDs) such as ibuprofen, naproxen, and aspirin as they may irritate your already sensitive digestive system.
Your doctor may recommend you take certain supplements such as iron, vitamin B12, or vitamin D, depending on what nutritional deficiencies you have as a result of Crohn’s disease.
If you feel like you need a Ph.D. in chemistry to negotiate your way through all these options, take comfort in knowing that most people feel the same. But your healthcare team is well-versed in the latest Crohn’s medications, and will be able to guide you through the process. Look at it this way: With so many choices, one almost certainly will work to help you manage your condition.
Crohn’s and Medication: Crohn’s & Colitis Foundation. (n.d.) “IBD Medication Guide.” ibdmedicationguide.org//browse
Crohn’s and Aminosalicylates: Crohn’s & Colitis Foundation. (2018). “Fact Sheet: Aminosalicylates” crohnscolitisfoundation.org/sites/default/files/legacy/assets/pdfs/aminosalicylates.pdf
Crohn’s and Corticosteroids: Crohn’s & Colitis Foundation. (2018). “Fact Sheet: Corticosteroids.” crohnscolitisfoundation.org/sites/default/files/legacy/corticosteroids.pdf
Crohn’s and Immunomodulators: Crohn’s & Colitis Foundation. (2018). “Fact Sheet: Immunomodulators.” crohnscolitisfoundation.org/sites/default/files/legacy/assets/pdfs/immunomodulators.pdf
Crohn’s and Biologics: Crohn’s & Colitis Foundation. (2018). “Fact Sheet: Biologics.” crohnscolitisfoundation.org/sites/default/files/legacy/assets/pdfs/emr/medications-biologic-therapy.pdf
Crohn’s and Antibiotics: Crohn’s & Colitis Foundation. (2018). “Fact Sheet: Antibiotics.” crohnscolitisfoundation.org/sites/default/files/legacy/assets/pdfs/antibiotics.pdf