Approach to medical therapy for IBD

IBD are chronic diseases, and most people with IBD require maintenance (long term) medication to keep them in remission.    The two main treatment approaches are the “STEP up” strategy and the “TOP down” strategy.

In the STEP up treatment strategy, clinicians will prescribe milder drugs that have less side effects, and increase doses or add stronger medications or more targeted medications when patients flare, and when patients require repeated courses of steroids.    When medications no longer work, or when there are complications of the IBD, surgery may be advised.  Clinical trials are considered the “next, next” line therapy once existing and approved therapies fail.

In the TOP down approach, clinicians will often start with stronger drugs that will control the disease faster or with more success, often starting with targeted therapies (e.g. biologics) or immunosuppressants, and in some cases with clinical trials or surgery.

Categories of IBD medications

5-aminosalicylates (5-ASA) agents

  • what are 5-ASA?
    • these are mesalamine containing compounds, with very few side effects
    • e.g. Asacol, Mesavant, Pentasa, Salofalk
  • who uses 5-ASA?
    • 5-ASA are most commonly used to treat ulcerative colitis, although some patients with Crohn’s colitis may find benefit
  • how are 5-ASA taken?
    • they can be taken orally once to several times a day
    • there are topical forms (liquids, foams, suppositories that melt) which were made to coat the inner lining of the rectum and last part of the colon
    • the topical therapies may help with healing of the rectum (and help with the symptoms of urgency, rectal bleeding)



  • what are immunosuppressants?
    • these are medications designed to suppress or modify the immune system
    • thiopurines (e.g. azathioprine (Imuran), 6-mercaptopurine (Purinethol)); e.g. Methotrexate
  • how are immunosuppressants taken?
    • thiopurines are oral tablets and are taken DAILY
    • methotrexate can be taken as oral tablets OR injections and is dosed WEEKLY
      • methotrexate is a teratogen (causes malformed fetus and miscarriage) and should be stopped at least 3 to 6 months BEFORE attempting to conceive)
    • remember to do your regular blood work as you increase the doses of these medications to reach your regular maintenance dose
  • PATIENT INFO HANDOUT – imuran and 6-MP
  • IMURAN – how to start imuran
  • 6-MP – how to start 6-MP



  • What are steroids?
    • these are medications that suppress the inflammation, but have many side effects
    • e.g. prednisone, budesonide
  • Can steroids be used long term?
    • steroids are NOT meant for long term use, they are NOT maintenance medications.  Steroids have too many side effects and should be tapered as soon as possible
  • How are steroids taken?
    • steroids can be oral tablets OR intravenous (in hospital administration)
    • steroids also come in topical (enemas or suppositories) form for distal colitis
  • What are the side effects of steroids?       
    • common side effects of steroids include
      • mood disturbance
      • insomnia
      • weight gain
      • skin acne
      • water gain (edema)
      • high blood pressure
      • bone loss (osteoporosis)
    • less common but significant side effects include
      • eye – glaucoma, cataracts
      • bone – bone death (Avascular necrosis)
      • blood sugar issues – diabetes



  • what are biologics?
    • these are medications that are designed to specifically target a protein or a pathway of the inflammatory and immune responses
  • which biologics are out there?
    • currently the approved biologics include antibodies (proteins that bind to other proteins) that block certain inflammatory pathways that are thought to lead to IBD
    • anti-tumour necrosis factor-alpha (anti TNF-a)
    • infliximab (Remicade, Inflectra), adalimumab (Humira), golimumab (Simponi)
    • anti-interleukin (anti IL12/23)
    • ustekinumab (Stelara)
    • anti-integrin (anti-a4b7 )vedolizumab (Entyvio)
  • how are these given?
    • these are given by intravenous infusions (IV), subcutaneous (just under the skin) injections (SC), or a combination of IV and SC
    • induction: these drugs require an induction period (meaning more frequent and higher doses of drugs at the beginning) in order to get the “drug level” high enough
    • maintenance: once you have the first induction doses, if the drug works, you will be kept on a schedule of every 1, 2, 3, 4 or more weeks depending on response to the drug and type of drug.  It is very important not to skip or be late for doses, otherwise you can develop antibodies (proteins that block the drug) and lose the effect of the drug
  • what is a drug level?
    • drug level refers to the amount of the drug in your blood – scientists and clinicians have studied the range of drug level that controls inflammation.
    • Individual people and different diseases types may require differnt minimum drug levels to get into and stay in remission.
  • what is an antibody level?
    • antibody is a protein that blocks something else – so an antibody to the biologic drug is protein your body makes that blocks the drug.
    • This can cause issues such as losing response to the drug, or developing reactions to the drug.
    • Your doctor may prescribe an immunosuppresant such as Imuran or Methotrexate in order to lower the changes of you developing antibodies to the biologic drugs.
    • The chances of you developing an antibody to the drug is higher if you have missed doses or delayed doses.
  • BIOLOGICS – pre biologic start up letter


What about IBD medications and Pregnancy?

  •      Click here for more information about IBD medications and pregnancy.