Table 1.
Currently available treatments for IBD in Canada
| Drug | Route of administration | Standard maintenance dose schedule | Treatment phase | Type of IBD | Common side effects and serious adverse reactions (selected) |
|---|---|---|---|---|---|
| Topical anti-inflammatory therapies | |||||
| 5-Aminosalicylates (5-ASA, mesalamine):Older generation (oral) • Sulfasalazine (SSZ) Newer generation (oral) • Pentasa • Salofalk • Mezavant • Octasa • Teva 5-ASA Enemas • Salofalk • Pentasa • Mezera Suppositories • Salofalk • Pentasa |
Oral, rectal (suppositories, foams, and enemas) | Oral: Daily Rectal: Daily, though twice weekly has been shown to be beneficial for maintenance of remission |
Induction, maintenance | Mild-to-moderate ulcerative colitis (oral); rectal therapy may be used in distal ulcerative colitis. May be beneficial in mild colonic Crohn’s disease, but this is controversial. |
Common side effects: • Nausea/vomiting • Paradoxical diarrhoea • Allergic hypersensitivity reactions (causing skin rash and mild fever) • Male infertility (SSZ) Serious adverse reactions (rare): • Serositis (pericarditis, serositis, mesenteritis) • Allergic interstitial nephritis • Cytopenias • Pancreatitis • Hepatitis |
| Topical corticosteroids: Budesonide (Entocort, Cortiment) |
Oral, rectal | Oral: Daily Rectal: Daily |
Induction | Mild-to-moderate Crohn’s disease (Entocort) or ulcerative colitis (Cortiment) | See below for corticosteroids N.B. Risk of steroid-related side effects markedly lower than prednisone or solumedrol |
| Non-targeted immunosuppressive therapies | |||||
| Corticosteroids (prednisone, prednisolone, methylprednisolone) | Oral (prednisone) or intravenous (prednisolone, methylprednisolone) | Daily | Induction | Crohn’s disease, ulcerative colitis | Common side effects: • Sleep disturbance • Irritability, mood swings • Mild anxiety or depression • Fluid retention • Increased appetite • Weight gain • Acne • Linear growth delay (children) • Myalgias, arthralgias Serious adverse reactions: • Opportunistic infections • Osteonecrosis • Osteoporosis • Diabetes mellitus • Hypertension • Cataracts • Muscle atrophy • Body fat redistribution (Cushingoid) |
| Cyclosporine | Oral or intravenous | Daily | Induction | Ulcerative colitis | Common side effects: • Hirsutism • Tremor • GI upset • Headache Serious adverse reactions: • Opportunistic infections • Seizures • Renal toxicity • Hypertension |
| Thiopurines (azathioprine, 6-mercaptopurine) | Oral | Daily | Maintenance | Crohn’s disease, ulcerative colitis | Common side effects: • GI upset • Hypersensitivity skin and joint reactions Serious adverse reactions: • Opportunistic infections • Pancreatitis • Bone marrow toxicity • Hepatotoxicity • Lymphoma • Non-melanoma skin cancer |
| Methotrexate | Oral, subcutaneous | Weekly | Maintenance | Crohn’s disease | Common side effects: • Flu-like symptoms • GI upset • Nausea, vomiting • Mucositis Serious adverse reactions: • Bone marrow toxicity • Hepatotoxicity, hepatic fibrosis • Pneumonitis, lung fibrosis |
| Targeted immuno-active therapies | |||||
| Biologics | |||||
| Anti-TNFs | |||||
| Adalimumab (Humira, Abrilada, Adalimumab injection, Amgevita, Hadlima, Hadlima Pushtouch, Hyrimoz, Hulio, Idacio, Simlandi, Hadlima, Yuflyma) | Subcutaneous | Every two weeks | Induction, maintenance | Crohn’s disease, ulcerative colitis | Common side effects: • Injection site reactions • GI upset • Hypersensitivity reactions (skin, joints) • Upper respiratory tract infections • Headache • Nausea Serious adverse reactions: • Opportunistic infections • Drug-induced lupus • Cardiomyopathy • Demyelinating neuropathy • Lymphoma • Melanoma |
| Golimumab (Simponi) | Subcutaneous | Every four weeks | Induction, maintenance | Ulcerative colitis | As per Adalimumab |
| Infliximab (Remicade Inflectra, Ixifi, Renflexis, Remsima, Remsima SC, Avsola) |
Intravenous | Every eight weeks | Induction, maintenance | Crohn’s disease, ulcerative colitis | As per Adalimumab Acute infusion reactions (including anaphylaxis) |
| Anti-integrins | |||||
| Vedolizumab (Entyvio) | Intravenous | Every eight weeks | Induction, maintenance | Crohn’s disease, ulcerative colitis | Common side effects: • Acute infusion reactions (IV) • Injection site reactions (SC) • GI upset • Hypersensitivity reactions (skin, joints) • Upper respiratory tract infections • Headache |
| Anti-IL-12/23s; Anti-IL-23s | |||||
| Ustekinumab (Stelara) (Anti-IL-12/23) |
Intravenous induction followed by subcutaneous maintenance | Every eight weeks | Induction, maintenance | Crohn’s disease, ulcerative colitis | Common side effects: • Injection site reactions • Upper respiratory tract infections • Headache |
| Risankizumab (Skyrizi) (Anti-IL-23) |
Intravenous induction followed by subcutaneous maintenance | Every eight weeks | Induction, maintenance | Crohn’s disease | Common side effects: • Injection site reactions • Upper respiratory tract infections • Headache |
| Small molecules | |||||
| Janus kinase (JAK) inhibitors | |||||
| Tofacitinib (JAK-1/2/3, TYK-2) |
Oral | Twice daily | Induction, maintenance | Ulcerative colitis | Common side effects: • GI upset • Hypersensitivity reactions • Upper respiratory tract infections • Headache • Elevated liver enzymes • Hypercholesterolemia Serious adverse reactions: • Opportunistic infections • Herpes Zoster (shingles) • Venous thromboembolism* • Major cardiovascular events* • Cancers* |
| S1P receptor modulators | |||||
| Ozanimod | Oral | Daily | Induction, maintenance | Ulcerative colitis | Common side effects: • GI upset • Upper respiratory tract infections • Pyrexia • Headache • Elevated liver enzymes Serious adverse reactions:† • Opportunistic infections • Hypertension • Bradycardia (rare) • Progressive multifocal leukoencephalopathy (rare) |
*Only demonstrated in studies in rheumatoid arthritis patients.
†Until more data available, extrapolated from studies in tofacitinib.