Biologics and Crohn’s Disease
Biologic medications, are a relatively new treatment for people with Crohn's Disease. They are medications that are made from things that are found in life and their products, mainly proteins. Biologics are antibodies which bind to specific parts (proteins) of the immune response, specifically in the gut lining. When bound to these factors involved in the immune response, biologics block normal function of the inflammation cascade and decrease inflammation. Basically, biologics increase the anti-inflammatory response to slow down inflammation, thereby improving the disease. Targets of biologics used to treat CD include tumor necrosis factor (TNF)-alpha, interleukins, adhesion molecules, colony-stimulating factors, and others. The biologics most commonly used in CD are adalimumab and infliximab.
How do you take biologics?
All biologics are administered as an infusion or injection. Infusions are usually given at an infusion center and take 30 minutes, one hour, or two hours to infuse. They are given at specific time intervals, usually every four or eight weeks after an initial induction period, depending on the medication. Injections are administered under the skin and can be done at home. After an initial induction period, injections are typically given every two to four weeks, depending on the medication.
When to use biologics
Biologics are extremely effective medications in treating any kind of active CD that is not controlled with other therapies. They are effective in treating CD affecting the colon (colitis), the portion of the small intestines connected to the first portion of the colon (ileocolitis), the small intestines (enteritis), abnormal connections between different portions of the gut wall or skin called fistulas, and disease around the anal canal (perianal). Biologics are also extremely effective in maintaining disease control, even when all other therapies have not worked.
Other Medications Used in CD
- 5-Aminosalicylates (5-ASA’s) - 5-ASAs, such as mesalamine and sulfasalazine, work to decrease inflammation at the level of the lining of the GI tract. These medications are administered as a tablet by mouth, enema, or rectal suppository. 5-ASA’s have a modest effect in treating active CD, and only in those with colitis or ileocolitis. Sulfasalazine is considered treatment of choice for active disease in the colon, more specifically, the left portion of the colon. 5-ASA’s do not help in active disease of the small intestines or in those who have fistulas or perianal disease. Mesalamine and sulfasalazine are not consistently effective in maintaining disease control once the active flare is treated.
- Corticosteroids - Corticosteroids, such as prednisone, methylpredisolone, and budesonide, suppress the immune system. They can be administered intravenously, orally, or through enemas and suppositories. Steroids are often used only to control an active flare, or “induce remission,” and not long term because they suppress the entire immune response with potential for significant side effects. The one exception is budesonide, which works locally to decrease inflammation, thereby resulting in minimal systemic effect. Budesonide is the first medication of choice for inducing remission in mildly to moderately active CD affecting the right colon and terminal ileum.
- Immunomodulators - Immunomodulators include 6-mercaptopurine (6-MP), azathioprine, and methotrexate. Azathioprine and 6-MP are tablets taken by mouth, whereas methotrexate is an injection administered weekly. Immunomodulators suppress the immune response so that ongoing inflammation cannot occur. They are effective in inducing remission in patients not responding to 5-ASAs and corticosteroids. They are also used in those with fistulas or perianal disease and are effective in maintaining remission. These medications can affect the liver and blood cells, therefore, blood counts and liver function tests need to be done frequently when they are being used.
- Antibiotics - The role of antibiotics in CD is controversial. Ciprofloxacin and metronidazole are two antibiotics that are often prescribed in conjuction with 5-ASA’s before initiating steroids in attempt to induce remission. Consistent studies showing efficacy of antibiotics used this way are limited. However, these antibiotics have been shown to be effective in treating or closing fistulas, especially perianal fistulas, and these medications are therefore first line therapy in these scenarios.
It is very important that you work with your doctor when taking any medication for CD and keep them informed of any symptoms you experience, either related to your CD or potential side effects of the medications. While all of these medications are safe, if you experience any side effects or develop fevers/symptoms of illness, you should contact your doctor. Also, it is imperative that you do not stop any medications on your own. If you do, only restart them with the guidance of your doctor, and not on your own.
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