Medication Options
*Rx = prescription
Medications used in Pediatrics ONLY
One form of treatment that can be used in pediatrics but not in adult care is enteral nutrition. Exclusive enteral nutrition is used in pediatrics to induce remission with newly diagnosed Crohn’s disease. Enteral nutrition is an entirely liquid diet (eg: Nutren® or Ensure®) that is given either through a small nasogastric (NG) tube directly into the stomach or small intestine. This treatment is hard to sustain for a long period of time as no other food can be consumed during this therapy, so is usually prescribed for only 6-8 weeks. It is used in place of prednisone to induce remission.
Medications used in Adults ONLY
New medications approved for the treatment of IBD are usually available for adult patients before they are approved for children. This is because in order for medications to be approved for use by Health Canada, there need to be clinical trials showing that they are beneficial – adult studies are usually done before pediatric studies.
Medication Safety
Whenever you begin a new medication, make sure that you have reviewed its use and potential side effects with the doctor or nurse as well as the pharmacist dispensing it. It is important to equip yourself with the knowledge of why you are taking something as well as how it works and might affect you. It is also critical that your gastroenterologist, family physician and pharmacist know all of the medications (including herbal remedies or supplements) you are taking, so be sure to update this information with them at each appointment if there are any changes.shutterstock_295142729
If you experience a side effect or worsening of symptoms, it is recommended that you speak with your family physician, IBD nurse, or gastroenterologist. If you have a fever while on corticosteroids, immunosuppressant and/or biologics, seek medical attention as this may be a sign of infection.
Safety of herbal remedies – You must let your physician know if you are taking any supplements or alternative medicines, as some of them may interact with your prescribed medications. Just because something is natural or herbal, this does not mean that it is necessarily safe.
If your medication makes you more sensitive to sun exposure (Ciprofloxacin, Sulfasalazine, Imuran, Methotrexate) wear sunscreen and talk to your physician about sun protective behaviours. Also note that you should not be drinking alcohol on certain medications listed above (Methotrexate, Metronidazole).
Everyone’s disease is a little bit different and that is why there are a variety of medication options. Some will work better or worse for other people. Whatever medication you are on, it is important to follow the prescribed schedule and dosage. If there are serious health risks with your medication, your gastroenterologist will have you complete regular bloodwork and it will be monitored for any blood count changes.
If you are pregnant or considering becoming pregnant, discuss medication options with your gastroenterologist. You must not take methotrexate if you are pregnant or planning to get pregnant. See the section below about pregnancy.
Medication adherence
Taking your medications as prescribed helps you stay in remission and avoid flares. If you feel well, that doesn’t mean you should stop your medications. IBD medications are not a “cure,” they are a long-term treatment that protects your GI tract from attack by your immune system. If you take away the medications, it would be like turning off the water hose fighting a house fire or throwing away a shield in a sword fight – meaning that inflammation would increase, potentially causing damage (sometimes irreversible) to your intestines and you could experience a flare.
Unfortunately, even if you always take your medications it doesn’t mean that you will always feel well and not have flares on your medications – but taking them does reduce this risk. It is a good idea to discuss your symptoms and any changes with your gastroenterologist so you can feel confident about taking your current medication or investigate other options together. Cutting back or increasing medications yourself is not a good idea. As adults, you need to make informed choices – you are the expert on your body, and you need to be the expert on your medications, too.
Duration of Treatment
Because of the chronic (lifelong) nature of IBD, it is likely that you will need to be on some form of medication for the foreseeable future. Some individuals with ulcerative colitis may be considered “cured” if they have their colon surgically removed and use a colostomy bag. However, for the majority of individuals with IBD, you will hopefully be on a maintenance therapy that keeps the disease under control and allows you to do what you want in life.
Taking medication to prevent inflammation and flares helps to prevent damage to your intestine. If you are not on medications or experience repeated flares of the disease, this can increase your risk of cancer. Also, you may have to take corticosteroids frequently, which is bad for your health.
If you are not on medications or stop taking them, your disease can advance to the point where it cannot be controlled effectively with medication.
Medication Failure
Traditionally the treatment of IBD has happened in a stepwise way, where if your disease gets worse, you are given a “stronger” medication. Usually the course goes from Aminosalicylates and antibiotics, to corticosteroids, immunosuppressants, and then biologics – this is what we call the IBD treatment pyramid.
IBD TREATMENT PYRAMIDTreatment Pyramid
Depending on the nature of your disease, gastroenterologists may start on the “top end of the pyramid” with biologics right away. The idea behind this is that some cases of IBD may be more aggressive, resistant to the “milder” medications and therefore be higher risk for causing damage to your GI tract – starting off with “stronger” medications might be necessary to prevent the damage in these cases. However, the disease does change over time and might stop responding to your medications. It is a good thing that there are a number of different therapies and combinations of medications that have been shown to work. Also, new biologics are being developed so if one doesn’t work another one potentially could. Lastly, sometimes surgery is required to induce remission of your disease – to remove the affected parts of your bowel.
Managing Prescriptions
TIPS TO REMEMBER
Oral/Rectal Medications
Injection/Infusion Medications
HOW TO FILL PRESCRIPTIONS
Depending on the type of medication you’re taking, you might have to call the pharmacy to get refills of your prescription. It’s best to do this a few days before you will need the medication, so that there is time for the prescription to be filled and for you to pick it up.
Some people may choose to fill their prescriptions at one pharmacy that has their insurance information and all of their medications on file. This is not only convenient but safeguards against any conflict in medications, since the pharmacist can see everything you’re taking.
If it is the first time you are filling the prescription, you will take the paper copy to your pharmacy. Make sure to bring your insurance coverage card so that the pharmacy can add it to your file, if it is not on there already.
Check the number of refills your doctor has authorized on the prescription and try to plan so you have enough medication to see you through to your next appointment. If you run out of refills, your pharmacist will have to fax a refill request to your gastroenterologist’s office.
If you need a refill of a prescription that is already on file with your pharmacy, you can show up and ask for it to be filled, or call in the refill. Calling in advance may result in less waiting around at the pharmacy. When calling in, the automated system will ask you for the prescription number – you can find this on your last medication packaging.
If you have more questions about prescriptions, you could ask your gastroenterologist, nurse, pharmacist, parent/guardian or even your insurance company in the case that something you want is not covered.
Biologics in adult care
There are presently 2 types of biologic medications (Remicade® & Humira®) available for pediatric patients. If these medications start before you move to Adult IBD Care it is important to continue to take these medications as scheduled.
If you live in Alberta these medications are paid for through a provincial pediatric program. This program will pay for Remicade® or Humira® until the day before your 18th birthday.
Both medications have patient support programs which is a free program to assist patients
Remicade®:
If you were receiving Remicade®, your parents would have been linked with a patient support coordinator with the Bio-Advance Program when you started this medication.
After transition from pediatrics to the Adult IBD gastroenterologist:
You will no longer be infused through the pediatric infusion clinic
You will also transition to a different Bio Advance Support Coordinator for Adult patients who reviews insurance coverage with patient, completes special authorization for drug coverage, complete orders for biologic therapy, helps you liaison with the infusion clinic
The Adult IBD gastroenterologist will write your prescriptions for your medication
You have a choice of whatever pharmacy you want to use but you will still be responsible for picking up your medication unless you coordinate delivery of this medication to the infusion clinic
Humira®:
If you were receiving Humira®, your parents would have been linked with a patient support coordinator with the Abbvie-care Program when you started this medication.
After transition from pediatrics to the Adult IBD gastroenterologist
You will also transition to a different Abbvie-care Patient Support Coordinator for Adult patients who reviews insurance coverage with you, completes special authorization for medication coverage, completes orders for biologic therapy
The Adult IBD gastroenterologist will write your prescriptions for Humira® once you are seen in clinic
Medications During Pregnancy
shutterstock_112397081During pregnancy, you may have to make some changes to your medications. Methotrexate is usually stopped 6 months before trying to get pregnant (for males and females) and cannot be taken during as it causes birth defects. For other medications, your gastroenterologist may change your infusion schedule slightly but will likely aim to continue your maintenance therapy as flaring during pregnancy is not ideal. If you are thinking of becoming pregnant or you become pregnant, you should talk to your doctor right away about the medications you are on. If you are pregnant or trying to conceive and not on a folic acid/folate supplement, you should ask your family physician, gastroenterologist or pharmacist as soon as possible about taking one. Folic acid supports neural tube development in the fetus.
If you are interested in learning more about pregnancy in IBD, check out this website.
IBD research
For ongoing studies in Canada, check out Crohn’s and Colitis Canada or ask your gastroenterologist if there is something going on at your healthcare centre.
Learn more about research studies going on in Edmonton at The Centre of Excellence for Gastrointestinal Inflammation and Immunity Research or if you’re interested in clinical trials involving new medications, see The Northern Alberta Clinical Trials and Research Centre or Gastrointestinal and Liver Disease Research Group.