Corticosteroids

There is evidence of increased mortality in IBD patients on long-term steroids. Due to the side-effects associated with steroids, it is important to try and keep patients in remission and prevent the need for multiple steroid courses. If IBD patients require more than two steroid courses over a period of 12 months, it shows their normal maintenance treatment is not effective and needs to be stepped up.

Patients with IBD often require repeated steroid courses, and need calcium and vitamin D supplements when these are prescribed. When requiring steroids for a flare, patients are even more likely to have nutritional deficits, making them a higher risk for osteopenia/osteoporosis.

A proton pump inhibitor such as omeprazole may also be prescribed to help reduce adverse effects of steroids such as GI bleeding or dyspepsia.

Aminosalicylates

It is thought that aminosalicylates have a protective effect in reducing the risk of IBD-associated colorectal cancers. Although there is a lack of long-term efficacy studies for this, UC patients are often prescribed aminosalicylates long-term, even when treatment is stepped up. Patients may prefer to take the full dose once a day or split it into two or three divided doses throughout the day. Once a day dosing may help with compliance.

Due to the risk of serious side-effects, full blood count, liver function tests and creatinine should be monitored as per the BNF recommendations for all brands of aminosalicylate.

Immunosuppressants/immunomodulators

The thiopurines (azathioprine and mercaptopurine) should be started at the full dose. There is no evidence that starting at low doses and then gradually increasing up to target improves safety or tolerance, and low-dose initiation may cause significant delay in achieving the correct target dose; thiopurines may take 12-16 weeks to start having a clinical effect.

The medication should be taken with meals and at least a glass of liquid (200ml). During treatment metabolite levels should be checked to ensure compliance and appropriate dosage of the azathioprine or mercaptopurine.

When monitoring azathioprine, mercaptopurine and methotrexate, patients should have regular blood tests (full blood count, liver and renal tests, C-reactive protein) while on treatment – at least every two weeks for the first month, monthly for the next three months, and then three-monthly thereafter.

With any immunomodulator, patients and their carers should be warned to report immediately any signs or symptoms of bone marrow suppression (e.g. inexplicable bruising or bleeding; infection).