1. Immunosuppressants
a. Achieves/maintain remission in moderate to severe disease
b. “steroid sparing”
c. Takes several weeks to months to see the full benefit
i. Often started with steroids which are then tapered off.
d. Azathioprine (AZA) and Mercaptopurine (MP)
i. MOA
1. T cell suppression, purine antagonist
2. MP is active metabolite of AZA
3. AZA is prodrug
ii. AE:
1. Bone marrow suppression, leukopenia
a. Monitor CBC weekly, then 2x/month, then q1-2 months
2. Opportunistic infections, flu-like symptoms seen
3. Pancreatitis, nephrotoxicity, hepatoxicity
a. Monitor lipase, kidney stuff, LFT (transaminase, bilirubin)
4. Lymphoma
iii. Dosed by mg/kg
e. Methotrexate (MTX) 15-25 mg IM/SQ weekly
i. Crohn’s only!
ii. AE:
1. N/V/D, stomatitis, hepatotoxicity, pneumonitis
a. LFT, chest-x ray every year
f. Cyclosporine 2-4 mg/kg/day IV; 5-6 mg/kg/day PO; x 3-6 months
i. UC only
ii. AE:
1. Paresthesia, HTN, HA, Increased LFT, Increased K, nephrotoxicity, infection, seizure
2. Anti-TNFa
a. Infliximab (Remicade)
i. CD and UC
ii. Chimeric monoclonal antibody
iii. MOA
1. Binds TNF-a inhibiting inflammatory effects in the GIT
iv. AE:
1. Serum sickness, reactivation of TB/HepB so must screen before start
v. ADR prevention
1. Slow/stop infusion
2. Corticosteroids
3. Antihistamines
4. Acetaminophen
b. Adalimumab (Humira) moderate/severe CD and UC
i. 46% remission rate but higher rate of relapse after DC due to ADRs
c. Certolizumab (Cimzia)
i. CD only
d. Vedolizumab
i. CD and UC
e. natalizumab (Tysabri)
i. CD only