Which drugs should i start with? Stronger or weaker?

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Regular Member

Date Joined Jan 2010
Total Posts : 31
   Posted 1/14/2010 7:26 AM (GMT -6)   
Just seen my specialist and he has told me he isnt 100% sure exactly how to start treating my Crohns. I have had it for 5 years without any treatment until a week ago and i was finally diagnosed with Crohns. He said i have 2 options, either start with strong drugs and work my way down over the years or start with softer drugs and work my way up throughout the years. He said he usually starts with the stronger one's because it can do alot of help to the system but at the minute i feel absolutely fine so on the other hand he is thinking about starting me on softer drugs. He said the decision is mine. I told him about this site and he asked me to post this so i can get some help deciding what i think is best. There is alot of side effects on the stronger drugs and i'll be exposed to loads of different infections and even cancer. Can anyone offer any opinions? confused

Regular Member

Date Joined Dec 2007
Total Posts : 414
   Posted 1/14/2010 8:50 AM (GMT -6)   
I personally think starting off weaker and getting stronger is the best way. If you start with the strong drugs like remicade you're then committed to it when a weaker, simpler drug could have done the job.

Back when I was first diagnosed the way treatment was started was steroids + a pentasa type drug, if that didn't do it than move up to the immuno-suppressents such azathioprine and methotrexate, if they didn't work and surgery was unsuitable then you'd be put on a biologic (remicade).

Now they put people straight onto Humira, been trying to convince me to go onto that as well....problem is theres now a lot more interference from drug reps in the NHS which unsettles me a lot!

I'd say if you were severely struggling - bedridden etc then jump straight to the strong drugs rather than waste time. But if you're kinda coping start off weaker and see how it goes.

Regular Member

Date Joined Aug 2006
Total Posts : 443
   Posted 1/14/2010 9:01 AM (GMT -6)   
I would always start with the mildest option and work up. Response to the biologic drugs (Remicade, etc.) doesn't last forever, so there is no sense starting them until nothing else works. There's been a lot of talk that maybe starting aggressively will change the course of the illness, but so far zero evidence to support that view.

Regular Member

Date Joined May 2009
Total Posts : 173
   Posted 1/14/2010 9:06 AM (GMT -6)   
I would say it depends on the case. Since you're doing well, start with the milder ones to attain and maintain remission. If someone is doing poorly I might go higher sooner to knock it back quicker.
"What can't be changed must be endured" - unknown

DX with distal Crohn's colitis Oct 2007, predominantly in rectum
Colozal (750mg): 3 pills 3xdaily
Cortifoam - 1 nightly
6MP - currently at 100mg and waiting for response......

Elite Member

Date Joined Apr 2005
Total Posts : 14995
   Posted 1/14/2010 9:07 AM (GMT -6)   
I agree with the other posters I would start with the weaker meds. I have had this dd for almost 35 years and I am maintained solely with Asacol and am currently in remission after having two resections in the last decade. I like to try to save the heavier meds for when or if "I" really need them. JMHO
Gail*Nanners* Co-Moderator for Crohns Disease & Anxiety/Panic
Crohn's Disease for over 34 years. Currently on Asacol, Prilosec, Estrace, Prinivil, Diltiazem, Percoset prn for pain, Zofran, Phenergan, Probiotics, Calcium, Vit D, and Xanax prn. Resections in 2002 & 2005. Also diagnosed w/ Fibromyalgia, Osteoarthritis, & Anxiety. Currently my Crohns is in remission, but my joints are going crazy!
*Every tomorrow has two handles.  We can take hold of it by the handle of anxiety, or by the handle of faith"*

Regular Member

Date Joined Dec 2007
Total Posts : 298
   Posted 1/14/2010 9:15 AM (GMT -6)   
To give proper advice, I think it might be helpful to know where your active CD is located (colon, ileum, etc.), what kind of symptoms you are having, and if your doc thinks you are at risk for complications, like a stricture.

Anyways, it is 100% a personal choice and depends on what you are comfortable with. These options are the "top-down" versus "step-up" approach to Crohn's. If you google those terms you will find articles discussing the merits of both and that might help you decide.

Right now there is not solid evidence that going on stronger drugs immediately will help in the long term. BUT it will get you to remission faster--that's just common sense and it's clinically proven. Usually it's a good thing because the patient has disabling symptoms and just wants relief.

Now that you are diagnosed you should do something. If you are not experiencing severe symptoms and the doc is giving you a choice, my gut would say to go with the weaker drugs if he is offering something like antibiotics or Entocort followed by a 5-ASA, imuran/6mp, or nothing just to see what happens. I agree that it's better to save the heavy hitting drugs for when you need them. But if the choice is prednisone versus Remicade or Humira... some might argue it is better to be immunomodulated versus totally immunosuppressed, and pred does have some gnarly side-effects of its own. In terms of the risk of cancer and infection, that is something you have to weight against the risks of untreated Crohn's...which can also lead to cancer, emergency surgery, etc.
July 2007 Drug-Induced Liver Injury
January 2008 Crohn's Ileitis
Currently trying... Enteral Nutrition, VSL#3, Primadophilus Reuteri, Folic Acid

Veteran Member

Date Joined Mar 2009
Total Posts : 1118
   Posted 1/14/2010 9:27 AM (GMT -6)   
Hi, I after having an op last Jan for crohns i was put on Asacol then Pentasa but couldn't get along with them, will be going on to azathorapine (sp?) after i get over my last adventure!!!!!! I want to save the stronger drugs for the future if i should need them. Bev x
Diagnosed at 13 now 43
Reversal of temp stoma scheduled 27th Jan 10 :-)
Meds: Iron syrup,Loperimide,Folic acid & Citalopram 60mg (for Anxiety.)

Never be afraid to try something new;
remember amateurs built the ark, professionals built the Titanic.

Regular Member

Date Joined Jan 2010
Total Posts : 448
   Posted 1/14/2010 9:40 AM (GMT -6)   
i disagree. Starting weaker means going stronger because active inflimation is running its coarse.. starting strong means possible long term remission.. i dount you would go weaker. a lot of good new drugs coming out.

Veteran Member

Date Joined Apr 2006
Total Posts : 1884
   Posted 1/14/2010 3:31 PM (GMT -6)   
It makes sense to try the meds with the least potential for serious side effects, first. BUT stick with them only if they provide full remission.
If they don't, then go up the ladder of the pyramid (link to pic below) to find a med that, as much as possible, stops Crohn's dead in its tracks.
I don't believe the disease should be allowed to fester, even mildly - the potential for permanent strictures, also for fistulas, abcesses, etc, is just too big.
Right now, my daughter is on LDN, but if we get even a hint that there is some festering, still, then she will make a change.  
Daughter (22) Dx'd Crohn's 3/06. Misdiagnosed for two years, including by top pediatric Crohn's specialist as stress. No symptoms for the past two years. Recent colonoscopy shows stricture gone but still two spots of inflammation in TI. Used LDN to taper off Entocort. Was on Entocort since April 06. Never had D. 4.5 mg LDN, SCD multivit, homemade yogurt, 5000IU vit D3, 500 mg calcium, 27 mg iron, monthly B12 shots, daily oral B12 1000. SCD diet modified to include potatoes and rice. 

Post Edited (njmom) : 1/14/2010 1:36:16 PM (GMT-7)

Veteran Member

Date Joined Feb 2009
Total Posts : 529
   Posted 1/14/2010 4:30 PM (GMT -6)   
My doctor started me off with Pentasa and I've been working my way up. In my opinion, this is the best way to treat the disease, because I'd rather not deal with potentially serious side effects unless I absolutely have to. Pentasa didn't work for me, Entocort helped me significantly, and a combination of Cipro and Flagyl has helped me get rid of the rest of the pain I have had. So far, this has been successful for me. My next option is Imuran/6MP. I know that this can cause the inflammation to fester longer, but unless you spend forever on each drug working your way up, I'd much prefer this to dealing with nasty side effects (I haven't had any side effects so far). I was on Pentasa for under a month (I had a nasty reaction for it) and I've been on Entocort since March of last year, and the Cipro/Flagyl for about a week now (I've got a 3-month course of them to take). If you start with a weaker med like Entocort, I would suggest that if your symptoms haven't started to improve within the first month, you move up to Prednisone. Just my 2 cents!

Veteran Member

Date Joined May 2009
Total Posts : 506
   Posted 1/14/2010 4:54 PM (GMT -6)   
It's really hard to say exactly what is right for any given situation. I don't think that I was ever really under control before I was on Remicade, and I got worse even when I was on Remicade. I'd like to think that most of the damage done was when I was on Imuran, and not when I was on Remicade, but it's just a guess. I basically lived off prednisone for 6 months of college, so I believe that's when it was done. In a way I wish I would have started further up the ladder, but with more aggressive drugs comes higher risks for side affects. I don't know if I could have avoided surgery by starting with Remicade, but I think there is a decent chance of that happening. When I wasn't responding to Cipro and Flagyl right after diagnosis, I had a conversation with my doc and we decided on the less aggressive Imuran than the biologics route, and I don't really think that, at the time, I made a mistake. I guess what I'm trying to say is start low, and if you're not getting the results you want, don't hesitate to demand something stronger.
Diagnosed with CD July 2007
Currently on Remicade, Imuran, probiotics, folic acid, multivitamin.
Resection December 2009

Amor fati - Nietzsche

Veteran Member

Date Joined Feb 2009
Total Posts : 1810
   Posted 1/14/2010 6:01 PM (GMT -6)   
They have treatment algorithms/protocols depending on where your disease is located, your symptoms, etc..... While, I totally respect a doctor who wants me to be on board with the treatment and gives me some choices, I like someone who is somewhat decisive, even if we disagree. lol.... The safe approach is to start out with a milder drug if you are not too sick, your doc should know this. Do some research on good sites. I saw the Johns Hopkins site that njmom gave us a link to and it was very informative. I think we all face this at some point in time. My doctor started me on colazal because it was one of the mildest drugs and I am allergic to sulfa. While I felt pretty miserable, I was not nearly critically ill with any of the complications like strictures and fistulas. For that, I am grateful. With that said, my meds quit working and so we are facing the same situation about meds. They are re scoping me tomorrow to see what's up. Good luck to you!! Welcome to the forum, it is awesome!!!
diagnosed 1/09 with "diverticular colitis" ?? location: sigmoid colon
localized scleroderma & IBS, low thyroid,claritin, advair, singulair, lisinopril, progesterone, colazal, fish oil, synthroid, zoloft, wellbutrin, VSL#3 probiotic, Vit. D
Blood test positive for Crohn's via prometheus ibd serology panel

Veteran Member

Date Joined Sep 2005
Total Posts : 517
   Posted 1/14/2010 6:16 PM (GMT -6)   
Regarding the sequence of antibiotics: although the sequence of antibiotics is typically begins with Cipro. The "correct" order of sequence (if MAP remedy antibiotics are considered) is to use MAP remedy antibiotics prior to beginning any antibiotics such as cipro. I say "correct" order as italics since the the effectiveness of MAP antibiotics may be diminished if the patient has already began on a Cipro regimen. (need source documentation for this but I can probably find it again) Give my response to doc and see what he says. true that TB test is to rule out TB, however the if MAP regimen using MAP antibiotics is used first this ensures ruling out TB related and since the crohns treatment [should] begin with MAP regimen antibiotics first, is thus also an advantage to target crohns relationship to TB pathology.

Veteran Member

Date Joined Dec 2009
Total Posts : 681
   Posted 1/14/2010 9:25 PM (GMT -6)   
thanks for that excellent link njmom
Male with Crohn's since 15 years old, diagnosed at age 46. Terminal ileum resected 2002. 5 months of remission. Crohn's has now been active since early 2003.Had a gall bladder removed Nov. of 2009. Currently on Remicade every 8 weeks, Nexium, Iron, B-12 injection every 4 weeks, Morphine Sulfate as needed for pain. Cymbalta for long term pain control.5-asa Salofalk, Entecort, Imuran and Prednisone in the past.

Regular Member

Date Joined Jan 2010
Total Posts : 31
   Posted 1/16/2010 9:20 AM (GMT -6)   
Thank you all for your help. Im scheduled for a Barium on 12th Feb. I assume I will no which way we are going to go after this date. Just wish I knew what to expect.

Elite Member

Date Joined Apr 2005
Total Posts : 14995
   Posted 1/16/2010 9:27 AM (GMT -6)   
Sheep I just wanted to add that whatever decision you make whether it is the weaker meds or stronger, be sure to always take your maintainence meds even when you start feeling better. This helps to keep the disease under control and to stop and keep it stopped with continually taken your meds. As for diet, whether its a low res diet, SCD or whatever should be continued also along with the meds to help you feel your best. But meds and diet should always be considered as complimentary of eachother. Good luck with your test, and let us know which way your doc is going. Hugs!
Gail*Nanners* Co-Moderator for Crohns Disease & Anxiety/Panic
Crohn's Disease for over 34 years. Currently on Asacol, Prilosec, Estrace, Prinivil, Diltiazem, Percoset prn for pain, Zofran, Phenergan, Probiotics, Calcium, Vit D, and Xanax prn. Resections in 2002 & 2005. Also diagnosed w/ Fibromyalgia, Osteoarthritis, & Anxiety. Currently my Crohns is in remission, but my joints are going crazy!
*Every tomorrow has two handles.  We can take hold of it by the handle of anxiety, or by the handle of faith"*

Regular Member

Date Joined Apr 2007
Total Posts : 40
   Posted 1/16/2010 1:13 PM (GMT -6)   
My GI said it was his job to get me by on the least amount of drugs as possible. Whether this is right or wrong I don't know but he is the doctor. Over the last 9 years I have tried many many drugs with no response but giving each one plenty of time before going to the next one. At least he is willing to talk about it with you. Good luck
Crohns dx in 2002. ilieum and colon resection 2002. Ilieum resection 2007.
Started Humira dec, 08

ski bum
Regular Member

Date Joined Jan 2007
Total Posts : 451
   Posted 1/16/2010 4:24 PM (GMT -6)   
I need to bump up my meds from Pentasa. I'm going to go with Imuran. My plan is to get a colonoscopy in two years and if my disease has progressed, to then bump it up to a biological. That's Plan A. If I don't make it to the two years, I'll go to Plan B or C. This is my second time chosing to start with the weaker meds and work up, if necessary. (After my resection, I started over again with Pentasa. After almost 2 years on Pentasa post-resection, I'm going to start Imuran).
50 y/o F. CD dx'd Aug 05. Initially on Pentasa, then Imuran 125 mg. Started Humira (very reluctantly) on 10/24/07. Ileocolectomy 4/08. Back on Pentasa as maintenance.

Julia Hill
Veteran Member

Date Joined Mar 2008
Total Posts : 543
   Posted 1/16/2010 10:04 PM (GMT -6)   
It is hard to say as everyone response differently. After 30 years of pred I think I would start on the Remicade as it has done more for me than any other drug. If you start with the big guns you reduce the amount of inflammation you could get and lets not forget the other meds aren't without their side effects also i.e. steroid dependant. You don't say where your crohn's is, and that does make a difference.

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