1.5 Chronic bowel disorders
Mesalazine (Pentasa® (tablets, granules), Asacol® (e/c tablets), Mezavant XL® (e/c tablets)) is indicated for the induction and maintenance of remission in ulcerative colitis and for Crohn's disease affecting the colon. It has fewer side-effects than sulfasalazine but retains those associated with the 5-aminosalicylic acid moiety. It is contra-indicated in patients with renal impairment.
Different formulations of mesalazine have different release characteristics and should not be regarded as interchangeable; the proprietary name should be specified. Pentasa® is the cheapest 5-ASA and should be considered first-choice. Patients previously maintained and stable on sulfasalazine, or another aminosalicylate, should not be changed to Pentasa®. Topical mesalazine Pentasa® retension enema, Pentasa® suppositories, Asacol® foam enema, Asacol® suppositories) is recommended for mild to moderate active proctitis and for maintenance of remission in distal ulcerative colitis with or without oral mesalazine but patients are unlikely to be compliant. Choice of topical formulation should be determined by the proximal extent of the inflammation along with patient preference.
Sulfasalazine (tablets, e/c tablets, suspension, suppositories) is suitable for maintenance of remission of disease in patients who are able to tolerate its side-effect profile. Sulfasalazine may be useful for patients with coexisting rheumatoid arthritis. See Shared Care Policy and Prescribing Information for monitoring requirements.
Prednisolone (tablets, soluble tablets, injection, suppositories, enema) is used for the induction and maintenance of remission in ulcerative colitis and Crohn's disease.
Topical prednisolone in the form of retention enema (Predsol®), suppositories and aerosol foam are used for acute exacerbations in patients with localised rectal disease. Topical corticosteroids are less effective than topical mesalazine and should be reserved as second-line therapy for patients unresponsive to topical mesalazine.
Oral treatment with prednisolone is appropriate for mild to moderate exacerbations and injectable methylprednisolone (proprietary name Solu-Medrone®) is reserved for moderate to severe exacerabations. See 6.3, Prescribing points for corticosteroids.
Balsalazide (750mg capsule) is available for restricted use under specialist supervision as a second-line treatment for use in patients with distal colitis.
Hydrocortisone (enema, proprietary name Colifoam®) is no longer the preparation of choice, prednisolone preparations being considered more effective. It is recommended only for continuing use in the limited number of patients who are stabilised on it.
Budesonide (CR capsules) is used for the treatment of mild to moderate Crohn's disease of the ileocaecal region.
Budesonide (3mg gastro-resistant capsule and 9mg gastro-resistant granules as Budenofalk®) is used for symptomatic relief of chronic diarrhoea due to collagenous colitis, and induction of remission in patients with active collagenous colitis.
Azathioprine (tablets) or mercaptopurine (tablets) are widely used and effective in the induction and maintenance of remission in ulcerative colitis and Crohn's disease as cotrocosteriod-sparing therapies (unlicensed indications). See Shared Care Policy and Prescribing Information for monitoring requirements.
Methotrexate (2.5 mg tablets) is effective for the induction and maintenance of remission in Crohn's disease. It used as a second-line immunosuppresant agent in patients resistant or intolerant to azathioprine or mercaptopurine [unlicensed indication]. See Shared Care Policy and Prescribing Information for monitoring requirements.
Ciclosporin (injection, capsules, liquid) by continuous intravenous infusion is effective as a salvage therapy for patients with severe acute ulcerative colitis refractory to corticosteroid therapy, who would otherwise face colectomy. Its main role is a bridge to thiopurine therapy (azathioprine or mercaptopurine) and oral treatment is rarely required for longer than 3 months [unlicensed indication].
Colestyramine (sachets) is indicated for control of diarrhoea in some patients with ileal Crohn's disease.
Infliximab (100mg vial, Remicade®) and adalimumab (40mg injection, Humira®), as per NICE TA187, are recommended as treatment options for adults with severe active Crohn's disease whose disease has not responded to conventional therapy (including immunosuppressive and/or corticosteroid treatments), or who are intolerant of or have contraindications to conventional therapy. Infliximab is also recommended as a treatment option for people with active fistulising Crohn's disease whose disease has not responded to conventional therapy (including antibiotics, drainage and immunosuppressive treatments), or who are intolerant of or have contraindications to conventional therapy.
Infliximab or adalimumab should be given as a planned course of treatment until treatment failure (including the need for surgery), or until 12 months after the start of treatment, whichever is shorter.
People should then have their disease reassessed to determine whether ongoing treatment is still clinically appropriate.
PRESCRIBING POINTS FOR DRUGS USED IN CHRONIC BOWEL DISORDERS
- Treatment should only be commenced in patients with proven disease.
- Aminosalicylates should be avoided in patients with salicylate hypersensitivity.
- Patients receiving aminosalicylates should be advised to report any unexplained bleeding, bruising, purpura, sore throat, fever or malaise that occurs during treatment. A blood count should be performed and the drug stopped immediately if there is suspicion of a blood dyscrasia.
- Patients with irritable bowel syndrome may benefit from adopting a high fibre diet or taking agents which increase stool bulk.
- Antispasmodics (see 1.2) may be useful as adjunctive treatment.
- Long-term use of rectal corticosteroids can lead to systemic side-effects.