Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.
Anti-inflammatory medications that decrease intestinal inflammation are
analogous to arthritis medications that decrease joint inflammation. Different
types of anti-inflammatory medications used in the treatment of Crohn's disease
are:
5 aminosalicylic acid (5-ASA) compounds such as sulfasalazine (Azulfidine) and
mesalamine (Pentasa, Asacol,
Dipentum, Colazal, Rowasa enema, Canasa suppository) that act via direct
contact (topically) with the inflamed tissue in order to be effective.
Corticosteroids that act systemically (without the
need for direct contact with the inflamed tissue) to decrease inflammation
throughout the body. Systemic corticosteroids have important and predictable
side effects if used long-term.
A new class of topical corticosteroid (for example,
budesonide [Entocort EC]) that acts via direct contact (topically) with the inflamed tissue.
This class of corticosteroids has fewer side effects than systemic
corticosteroids which are absorbed into the body.
Antibiotics such as metronidazole (Flagyl) and
ciprofloxacin (Cipro) that
decrease inflammation by an unknown mechanism
5-ASA (mesalamine) oral medications
5-aminosalicylic acid (5-ASA), also called mesalamine, is similar chemically
to aspirin. Aspirin is an
anti-inflammatory drug that has been used for many years for treating arthritis,
bursitis, and tendonitis (conditions of tissue inflammation). Aspirin, however,
is not effective in treating Crohn's disease and ulcerative colitis, and even
may worsen the inflammation. Aspirin, however, is not effective in treating Crohn's disease and ulcerative colitis and may even worsen the inflammation. Recent studies suggest that aspirin might actually decrease future risk of developing colorectal cancer in the general population.
On the other hand, 5-ASA can be effective in
treating Crohn's disease and ulcerative colitis if the drug can be delivered
topically onto the inflamed intestinal lining. For example, mesalamine (Rowasa) is an enema
containing 5-ASA that is effective in treating inflammation in the rectum.
However, the enema solution cannot reach high enough to treat inflammation in
the upper colon and the small intestine. Therefore, for most patients with
Crohn's disease involving both the ileum (distal small intestine) and colon,
5-ASA must be taken orally.
If pure 5-ASA is taken orally, however, most of the 5-ASA would be absorbed
in the stomach and the upper small intestine, and very little 5-ASA would reach
the ileum and colon. To be effective as an oral agent in treating Crohn's
disease, 5-ASA has to be modified chemically to escape absorption by the stomach
and the upper intestines.
Sulfasalazine (Azulfidine)
Sulfasalazine (Azulfidine) was the first modified 5-ASA compound used in the
treatment of Crohn's colitis and ulcerative colitis. It has been used
successfully for many years to induce remissions among patients with mild to
moderate ulcerative colitis. Sulfasalazine also has been used for prolonged periods
for maintaining remissions.
Sulfasalazine consists of a 5-ASA molecule linked chemically to a
sulfapyridine molecule. (Sulfapyridine is a sulfa antibiotic.) Connecting the
two molecules together prevents absorption by the stomach and the upper
intestines. When sulfasalazine reaches the ileum and the colon, the bacteria that
normally are present in the ilium and colon break the link between the two molecules. After breaking
away from 5-ASA, sulfapyridine is absorbed into the body and later eliminated in
the urine. Most of the active 5-ASA, however, is available within the terminal
ileum and colon to treat the colitis.
Most of the side effects of sulfasalazine are due to the sulfapyridine molecule.
These side effects include nausea, heartburn, headache, anemia, skin rashes,
and, in rare instances, hepatitis and kidney inflammation. In men, sulfasalazine
can reduce the sperm count. The reduction in sperm count is reversible, and the
count usually becomes normal after the sulfasalazine is discontinued or changed to
a different 5- ASA compound.
Because the newer 5-ASA compounds, for example, mesalamine (Asacol and
Pentasa), do not have the sulfapyridine component and have fewer side effects
than sulfasalazine, they are being used more frequently for treating Crohn's disease and ulcerative colitis.
Asacol
Asacol is a tablet consisting of the 5-ASA compound surrounded by an acrylic
resin coating. Asacol is sulfa-free. The resin coating prevents the 5-ASA from
being absorbed as it passes through the stomach and the small intestine. When
the tablet reaches the terminal ileum and the colon, the resin coating
dissolves, and the active 5-ASA drug is released.
Asacol is effective in inducing remissions in patients with mild to moderate
ulcerative colitis. It also is effective when used in the longer term to
maintain remissions. Some studies have shown that Asacol also is effective in
treating Crohn's ileitis and ileo-colitis, as well as in maintaining remission
in patients with Crohn's disease.
The recommended dose of Asacol for inducing remissions is two 400 mg tablets
three times daily (a total of 2.4 grams a day). At least two tablets of Asacol
twice daily (1.6 grams a day) is recommended for maintaining remission.
Occasionally, the maintenance dose is higher.
As with Azulfidine, the benefits of Asacol are dose-related. If patients do
not respond to 2.4 grams a day of Asacol, the dose frequently is increased to
3.6 - 4.8 grams a day to induce remission. If patients fail to respond to the
higher doses of Asacol, then other alternatives such as corticosteroids are
considered.
Pentasa
Pentasa is a capsule consisting of small spheres containing 5-ASA.
Pentasa is
sulfa-free. As the capsule travels down the intestines, the 5-ASA inside the
spheres is released slowly into the intestine. Unlike Asacol, the active drug
5-ASA in Pentasa is released into the small intestine as well as the colon.
Therefore, Pentasa can be effective in treating inflammation in the small
intestine and is currently the most commonly used 5-ASA compound for treating
mild to moderate Crohn's disease in the small intestine.
Patients with Crohn's disease occasionally undergo surgery to relieve small
intestinal obstruction, drain abscesses, or remove fistulae. Usually, the
diseased portions of the intestines are removed during surgery. After successful
surgery, patients can be free of disease and symptoms (in remission) for a
while. In many patients, however, Crohn's disease eventually returns. Pentasa
helps maintain remissions and reduces the chances of the recurrence of Crohn's
disease after surgery.
In the treatment of Crohn's ileitis or ileocolitis, the dose of Pentasa
usually is four 250 mg capsules four times daily (a total of 4 grams a day). For
maintenance of remission in patients after surgery, the dose of Pentasa is
between 3-4 grams daily.
Olsalazine (Dipentum)
Olsalazine (Dipentum) is a capsule
filled with a drug in which two molecules of 5-ASA are joined
together by a chemical bond. In this form, the 5-ASA cannot be absorbed from the
stomach and intestine. Intestinal bacteria are able to break apart the two
molecules releasing the active individual 5-ASA molecules into the intestine.
Since intestinal bacteria are more abundant in the ileum and colon, most of the
active 5-ASA is released in these areas. Therefore, olsalazine is most effective
for disease that is limited to the ileum or colon. Although clinical studies
have shown that olsalazine is effective for maintenance of remission in ulcerative
colitis, up to 11% of patients experience diarrhea when taking olsalazine. Because
of this, olsalazine is not often used. The recommended dose of olsalazine is 500 mg twice a day.
Balsalazide (Colazal)
Balsalazide (Colazal)
is a capsule in which the 5-ASA is linked by a chemical bond
to another molecule that is inert (without effect on the intestine) and prevents the
5-ASA from being absorbed. This drug is able to travel through the intestine
unchanged until it reaches the end of the small bowel (terminal ileum)
and colon. There, intestinal bacteria split the 5-ASA and the
inert molecule releasing the 5-ASA. Because intestinal bacteria are most abundant in
the terminal ileum and colon, balsalazide is used to treat
inflammation predominantly localized to the colon.
Side effects of oral 5-ASA compounds
The 5-ASA compounds have fewer side effects than Azulfidine and also do not
reduce sperm counts. They are safe medications for long-term use and are
well-tolerated.
Patients allergic to aspirin should avoid 5-ASA compounds because they are
similar chemically to aspirin.
Rare kidney and lung inflammation has been reported with the use of 5-ASA
compounds. Therefore, 5-ASA should be used with caution in patients with kidney
disease. It also is recommended that blood tests of kidney function be done
before starting and periodically during treatment.
Rare instances of worsening of diarrhea, cramps, and abdominal pain, at times
accompanied by fever, rash, and malaise, may occur. This reaction is believed to
represent an allergy to the 5-ASA compound.
Crohn's Disease - Symptoms at Onset of DiseaseQuestion: The symptoms of crohn's disease can vary greatly from patient to patient. What were your symptoms at the onset of your disease?
Abdominal pain is pain in the belly and can be acute or chronic. Causes include inflammation, distention of an organ, and loss of the blood supply to an organ. Abdominal pain can reflect a major problem with one of the organs in the abdomen such as the appendix, gallbladder, large and small intestine, pancreas, liver, colon, duodenum, and spleen.
Diarrhea is a change is the frequency and looseness of bowel movements. Cramping, abdominal pain, and the sensation of rectal urgency are all symptoms of diarrhea. Absorbents and anti-motility medications are used to treat diarrhea.
Gallstones are stones that form when substances in the bile harden. Gallstones (formed in the gallbladder) can be as small as a grain of sand or as large as a golf ball. There can be just one large stone, hundreds of tiny stones, or any combination. The majority of gallstones do not cause symptoms.
Pink eye, also called conjunctivitis, is redness or irritation of the conjunctivae, the membranes on the inner part of the eyelids and the membranes covering the whites of the eyes. These membranes react to a wide range of bacteria, viruses, allergy-provoking agents, irritants, and toxic agents.
Anemia is the condition of having less than the normal number of red blood cells or less than the normal quantity of hemoglobin in the blood. The oxygen-carrying capacity of the blood is, therefore, decreased.
Colon cancer is a malignancy that arises from the inner lining of the colon. Most, if not all, of these cancers develop from colonic polyps. Removal of these precancerous polyps can prevent colon cancer.
Anal itching is the irritation of the skin at the exit of the rectum, known as the anus, accompanied by the desire to scratch. Causes include everything from irritating foods we eat, to certain disease and infections. Treatment options include local anesthetics, vasoconstrictors, protectants, astringents, antiseptics, keratolytics, analgesics, and corticosteroids. If condition persists, a doctor examination may be needed to identify an underlying cause.
Clostridium difficile (C. difficile) is a bacterium, and is one of the most common causes of infection of the colon. C. difficile spores are found frequently in hospitals, nursing homes, extended care facilities, and nurseries for newborn infants. They can be found on bedpans, furniture, toilet seats, linens, telephones, stethoscopes, fingernails, rings, floors, infants' rooms, and diaper pails. They even can be carried by pets. Antibiotic-associated (C. difficile) colitis is an infection of the colon caused by C. difficile that occurs primarily among individuals who have been using antibiotics. Treatment for C. difficile colitis hydration, replenishment of electrolyte deficiencies, discontinuing the antibiotic that caused the colitis, and using antibiotics to eradicate the C. difficile bacterium.
Ulcerative colitis is a chronic inflammation of the colon. Symptoms include abdominal pain, diarrhea, and rectal bleeding. Ulcerative colitis is closely related to Crohn's disease, and together they are referred to as inflammatory bowel disease. Treatment depends upon the type of ulcerative colitis diagnosed.
Small intestinal bacterial overgrowth (SIBO) refers to a condition in which abnormally large numbers of bacteria (at least 100,000 bacteria per ml of fluid) are present in the small intestine and the types of bacteria in the small intestine resemble more the bacteria of the colon than the small intestine. There are many conditions associated with small intestinal bacterial overgrowth, to include: diabetes, scleroderma, Crohn's disease, and others. There is a striking similarity between the symptoms of irritable bowel syndrome and SIBO. It has been theorized that SIBO may be responsible for the symptoms of at least some patients with irritable bowel syndrome. Symptoms of SIBO include: excess gas, abdominal bloating, diarrhea, and abdominal pain.
Ankylosing spondylitis is a type of arthritis that causes chronic inflammation of the spine. The tendency to develop ankylosing spondylitis is genetically inherited.
Psoriatic arthritis is a disease that causes skin and joint inflammation. Symptoms include painful, stiff, and swollen joints, tendinitis, and organ inflammation. Treatment involves antiinflammatory medications and exercise.
Inflammation of the inner lining of the colon is referred to as colitis. Symptoms of the inflammation of the colon lining include diarrhea, pain, and blood in the stool. There are several causes of colitis including infection, ischemia of the colon, inflammatory bowel disease (Crohn's disease, Ulcerative colitis, or microscopic colitis). Treatment depends on the cause of the colitis.
Canker sore is a small ulcer crater in the lining of the mouth. Canker sores are one of the most
common problems that occur in the mouth. Canker sores typically last for
10-14 days and they heal without leaving a scar.
The inflammatory bowel diseases (IBD) are Crohn's disease (CD) and ulcerative colitis (UC). The intestinal complications of Crohn's disease and ulcerative colitis differ because of the characteristically dissimilar behaviors of the intestinal inflammation in these two diseases.
Gastritis is an inflammation of the stomach lining. Causes of gastritis include drinking too much alcohol, medications such as NSAIDs, ibuprofen, aspirin, H. pylori infection, severe infections, burns, anemia, and autoimmune disorders. Gastritis is diagnosed with endoscopy, blood tests, or stool tests. Treatment depends upon the cause of gastritis.
Erythema nodosum is a skin inflammation that results in reddish, painful, tender lumps most commonly located in the front of the legs below the knees. Erythema nodosum can resolve on its own in 3 to 6 weeks, leaving a bruised area. Treatments include anti-inflammatory medications and cortisone by mouth or injection.
Corticosteroid drugs such as prednisone and prednisolone are commonly used to treat asthma, allergic reactions, RA, and IBD. Steroids such as these do have serious drawbacks such as steroid withdrawal symptoms such as: fatigue, weakness, decreased appetite, weight loss, nausea, vomiting, abdominal pain, and diarrhea. Speak with your healthcare provider prior to tapering off steroid medications.
Chronic pain is pain (an unpleasant sense of discomfort) that persists or progresses over a long period of time. In contrast to acute pain that arises suddenly in response to a specific injury and is usually treatable, chronic pain persists over time and is often resistant to medical treatments.
Bronchiectasis is a condition in which the bronchial tubes of the lung become damaged. Inflammation from infection or other causes destroys the smooth muscles of the bronchial tubes. Bronchiectasis is a form of COPD (which includes emphysema and chronic bronchitis). There are three primary types of bronchiectasis: 1) cylindrical bronchiectasis; 2) saccular bronchiectasis; and 3) cystic bronchiectasis. Bronchiectasis may also be acquired or congenital. The most common symptoms of bronchiectasis are recurrent cough and sputum production. There is no cure for bronchiectasis. Treatment is often geared toward controlling the symptoms of bronchiectasis.
Primary sclerosing cholangitis (PSC) is a chronic, progressive disease of the bile ducts that channel bile from the liver into the intestines. There is an association between primary sclerosing cholangitis and ulcerative colitis and Crohn's disease. Symptoms of primary sclerosing cholangitis include abnormal liver blood tests, itching, fatigue, and jaundice. Primary sclerosing cholangitis is treated with medications and in some cases, liver transplant.
Digestion is the complex process of turning food you eat into the energy you need to survive. The digestive process also involves creating waste to be eliminated, and is made of a series of muscles that coordinate the movement of food.
Vitamin D deficiency has been linked with rickets, cancer, cardiovascular disease, severe asthma in children and cognitive impairment in older adults. Causes include not ingesting enough of the vitamin over time, having limited exposure to sunlight, having dark skin, and obesity. Symptoms include bone pain and muscle weakness. Treatment for vitamin D deficiency involves obtaining more vitamin D through supplements, diet, or exposure to sunlight.
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