COMBINING MEDICINES FOR MORE EFFECTIVE TREATMENT IN IBD

Because treatments for IBD don't work for everyone or because the medicines sometimes lose their effectiveness, medicines are sometimes used together to try to provide better results. The combination of 2 different medicines can prove better than using either one of them alone, but there is always a concern that some combinations may also increase their side effects, especially severe infections or a greater risk of tumors. 

Rectal Medicines + Medicines by Mouth

Medicines taken by mouth or even those given by injection don't seem to work in the rectum sometimes. There may be patches of Crohn's disease or ulcerative colitis higher up as well that needs treatment too, so rectal medicines and oral (by mouth), shots or intravenous medicines may be used together to target these different areas. 

Thiopurines and Anti-TNFs 

The Anti-TNFs work well in the beginning for most people. But for some, they start to lose effectiveness over time, especially if antibodies build up. Thiopurines can be given at the same time or added later to decrease the antibodies, which seems to maintain the effectiveness of the anti-TNFs. 

However, the combination doesn't work for everyone or for all the anti-TNF medicines (thiopurines work better infliximab (Remicade) than with adalimumab (Humira). And some studies actually show a decrease in the antibodies but no difference in hospitalizations when the 2 medicines are used together. The combination can allow more shingles (Herpes zoster) and yeast infections to develop. Studies have also shown that a particular type of cancer (lymphoma) is more likely when the combination is used. Study models suggest that if 100,000 people using infliximab alone, 40 would be likely to get a lymphoma. If a thiopurine is added, that number goes up to 60- a small number overall, but it does indicate a greater risk (C Siegel and others, Clinical Gastroenterology and Hepatology, 2012, pages 46-51). There's also a risk of a very rare, but deadly type of lymphoma (hepatosplenic lymphoma) that can develop with this combination or with just a thiopurine by itself. This happens especially in young boys (average of 22 ½ years of age), but only once in over 3500 young men.

These risks have changed the combination so most teens have methotrexate added to their anti-TNF medicine, when a combination is needed to lessen side effects. 

Combining Biologics

When several medicines fail in very difficult cases, several of the biologics are being combined to try and prevent surgery. These are currently random situations to date, so it's still too early to predict whether these combinations will work or if the combinations will cause more concern for side effects developing.  

IBD Diets and Medicines

Trials are underway to understand how the combination of one of the IBD diets can be used along with an immune-acting medicine to produce a better result. No definite conclusions or even early ones have been reached.