Antidiarrhoeals

Loperamide (Imodium, Arret), codeine phosphate and diphenoxylate (Lomotil) help to reduce diarrhoea (the passing of loose, watery stools). Antidiarrhoeals slow down the contractions (muscle movements) of the bowel, so that food takes longer to pass through your gut. This allows more water to be absorbed from the bowel into the body, which results in firmer stools that are passed less often.

Antidiarrhoeals should not be taken if you are having a significant flare-up, as this can occasionally lead to a serious complication called toxic megacolon. You may not be able to take antidiarrhoeals if you have a narrowing of the bowel called a stricture.

Abdominal cramps and constipation can be a side effect of antidiarrhoeals, and sometimes they can cause hard stools that are difficult or painful to pass.

Antispasmodics

Antispasmodics such as mebeverine (Colofac), hyoscine butylbromide (Buscopan) and alverine citrate (Spasmonal) reduce painful gut cramps or spasms by relaxing the intestinal muscles. These medicines are most likely to be recommended for people with Irritable Bowel Syndrome (IBS), but they may also be helpful for the IBS-like symptoms sometimes experienced by people with Crohn's or Colitis.

Painkillers

If you need to take over-the-counter painkillers for gut or joint pain, paracetamol is likely to be the safest option. It is best to avoid ibuprofen and diclofenac, which are non-steroidal anti-inflammatory drugs (NSAIDs). While they can be effective, there is evidence that they may make other Crohn's and Colitis symptoms worse, or possibly trigger a flare-up. Some people may also be affected in the same way by aspirin.

For severe acute pain or after an operation, opiates such as codeine may be prescribed. These can cause side effects such as nausea, constipation, sedation and altered mood. Opiates can also lead to dependence and addiction if used regularly.
If you find you have ongoing problems with pain and need to keep taking painkillers, talk to your doctor about your symptoms, as other treatment may be more appropriate.

Bulking agents

Bulking agents or ‘bulk formers’ contain a water-absorbent plant fibre– usually ispaghula or stercula. Popular brands include Fybogel, Isogel and Normacol. These come as granules which, when taken  with plenty of water, swell up inside the bowel to thicken liquid faeces or soften hard stools. The fibre also provides bulk to help the bowel to work normally.

Bulking agents can be particularly helpful in treating diarrhoea if you have had a colectomy with ileo-rectal anastomosis, an operation to remove your colon in which your small intestine is joined to your rectum. However, you should not take bulking agents if you have a stricture (narrowing) of the bowel.

Bile salt binders

Bile salts are naturally released from the liver to help with digestion, and are then reabsorbed in the ileum (the lower part of the small intestine). If you have Crohn’s and have had surgery to remove the ileum, higher levels of bile salts can drain into the colon and cause watery diarrhoea.

Bile salt binders such as colestyramine (Questran), colestipol (Colestid) and colesevelam combine with the bile salts and prevent them from reaching the colon. This helps reduce the diarrhoea. Colestryramine and colestipol are in powder form and can be mixed with water, juice or soft food. Colesevelam comes as a capsule, which some people find more convenient.

Possible side effects include indigestion, abdominal bloating and discomfort, nausea and constipation. Bile salt binders can also affect how well other drugs are absorbed, so other drugs should be taken at least one hour before, or four hours after, the bile salt binder.

Laxatives

Constipation - passing stools fewer than three times per week, needing to strain, or passing hard stools - can also be a symptom of Crohn's and Colitis. Laxatives can help to relieve constipation. Osmotic laxatives are usually considered the best type of laxative for people with Crohn's or Colitis. They include lactulose and macrogol. Osmotic laxatives increase the amount of water in your bowel to make your poo softer and easier to pass.  Laxatives can cause diarrhoea, wind and stomach cramps, especially at the start of treatment.

Many of the companies that make these medicines recommend that they are not used in people with acute or severe Crohn’s or Colitis. Your doctor or nurse may have prescribed these for you. If so, they will have considered the advantages and disadvantages of you taking them. Speak to your IBD team before trying laxatives or if you have any concerns about taking them.

Anti-foaming agents

People with Crohn's or Colitis often report feeling bloated or having excess gas. If this is a problem for you, an anti-foaming agent such as Simethicone, which disperses bubbles of trapped wind, may be helpful. Simethicone can be bought over-the-counter in products such as Wind-Eze tablets and WindSetler.

Anti-sickness medication

Some medications for Crohn’s and Colitis, as well as the conditions themselves, can occasionally cause nausea and vomiting. People experiencing this may be prescribed anti-sickness medication such as metoclopramide, ondansetron or cyclizine. These may be given as tablets or intravenous infusion. Side effects of these drugs can include drowsiness, uncontrollable movements of the body, headaches, diarrhoea and constipation.

Antibiotics are occasionally used as a treatment for other Crohn's or Colitis symptoms, often together with other drugs. This is because while the exact cause of Crohn's and Colitis  is still unknown, it is very likely that it involves an abnormal reaction of the immune system to intestinal bacteria. Antibiotics could potentially help control symptoms of Crohn's or Colitis  by reducing these bacteria, and may also have immunosuppressant effects.

Research has shown that antibiotics have no consistent benefit for Colitis symptoms, so are not usually used. There is some evidence to suggest that they are effective in treating Crohn’s, in particular Crohn’s Colitis (Crohn’s in the colon). Antibiotics may also help prevent Crohn’s from coming back after surgery.

Using antibiotics can sometimes lead to the development of Clostridium difficile (C. difficile) infection. Clostridium difficile are potentially dangerous bacteria that can cause diarrhoea and serious complications. People with Crohn’s and Colitis are at a higher risk of C. difficile infection, and so may need to take extra care with antibiotics.

Metronidazole (Flagyl)

This is the most commonly prescribed antibiotic for Crohn’s. It is usually taken as a tablet, but it can be taken as a suppository or be given by injection. Side effects may include nausea, lack of appetite and a metallic taste in the mouth. More rarely, long-term use can cause nerve damage and a tingling in the hands and feet. It is best to avoid drinking alcohol while taking metronidazole and for at least two days following the last dose, as there can be an interaction.

Ciprofloxacin

Ciprofloxacin is also used for the treatment of Crohn’s and has been found to be as effective as metronidazole, with fewer side effects. It is normally taken as a tablet, but can be given by injection. Common side effects include nausea and diarrhoea. Some people also experience tendon damage or photosensitivity (sensitivity to sunlight). Ciprofloxacin may also interact with some of the other medications used for Crohn's and Colitis, such as ciclosporin, methotrexate and iron supplements.

Many people with Crohn’s and Colitis are iron deficient, which can lead to anaemia, a lower level of haemoglobin in red blood cells. Iron deficiency can make you feel very tired, and supplements may be needed to increase iron levels. Even if you are not anaemic, your specialist may test the iron saturation in your blood, as low iron stores may contribute to fatigue in Crohn's or Colitis.

Side effects of oral iron supplements can include constipation, blackened stools and stomach pain. Some people with Crohn's or Colitis find that ferrous sulphate iron tablets make their symptoms worse. In these cases, a type of iron called ferric maltol may be better tolerated, as it tends to have fewer side effects.

Ferric maltol (Feraccru) has been developed specifically for people with Crohn's or Colitis, and has been shown to be effective in treating iron deficiency in people who have not responded to traditional iron tablets. Feraccru is not currently available everywhere, and cannot be taken if you are in an Crohn's or Colitis flare-up or have a haemoglobin level that is less than 9.5 g/dL.

For people who are severely anaemic or cannot tolerate iron tablets, iron infusions are sometimes recommended. This is a very quick way to get iron into the bloodstream, and is done at the hospital as an outpatient. A thin tube called a cannula is placed in your vein and attached to a drip that slowly delivers a solution containing iron into the body. It can take from 30 minutes to several hours to complete the drip, and you will be monitored for a while afterwards to make sure you do not have an allergic reaction.

For young people who cannot tolerate iron tablets, over-the-counter multivitamins containing iron and vitamins may be recommended.

Vitamin B12 injections

Vitamin B12 performs several important functions in the body, including forming red blood cells and keeping the nervous system healthy. People with Crohn’s Disease who have had their ileum removed, or who have inflammation in that area, can have difficulties absorbing vitamin B12 from food. This can lead to vitamin B12 deficiency anaemia, which is usually treated with regular injections of the vitamin in a form called hydroxocobalamin.

Calcium and vitamin D supplements

People with Crohn's and Colitis are at higher risk of developing thinner and weaker bones, especially if they are on steroid medication. You may be prescribed a calcium supplement with added vitamin D, such as Adcal-D3, to help protect your bones. Side effects of these supplements are rare, but may include constipation, skin rash, and hypercalcaemia (too much calcium in your blood) or hypercalciuria (too much calcium in your urine). See our information Bones for more details about protecting your bones.

Folic acid

If you are taking an immunosuppressant called methotrexate, you are likely to be prescribed folic acid to help reduce some of the possible side effects, such as nausea and vomiting. Usually it is taken once a week, but not on the same day as methotrexate. However, a number of different regimes may be used. Folic acid and zinc and magnesium supplements are also sometimes needed in people who have had extensive surgery and are unable to absorb these nutrients fully.

Probiotics

Probiotics are live microorganisms that aim to improve the health of your gut. Your gut contains trillions of different bacteria, but sometimes illness or medical treatment can change the amount in the gut. Probiotics may help to repopulate your gut with friendly bacteria.

Probiotics can be added to drinks or yoghurts, or taken in capsule form. They generally produce fewer side effects than other treatments, but can occasionally cause bloating, wind, and in rarer cases, infections.

Some small studies have found that certain high-potency probiotics may help people with Colitis stay in remission. But it is currently not recommended because other more effective options are available. As yet, there is no clear evidence that probiotics can help induce or maintain remission in people with Crohn’s .

Probiotics are not available on prescription, and can be expensive. If you do decide to take probiotics, try find one with lots of bacteria in them. High-potency probiotics have 450 billion bacteria with several strains, but probiotics sold in supermarkets typically only contain 10 billion bacteria and one strain. A lot of the bacteria can be destroyed by stomach acid, so the actual amount of bacteria reaching the bowel is not known.

Research funded by Crohn’s & Colitis UK found that people with Crohn’s and Colitis have less of a bacterium called bifidobacterium in their guts compared to healthy people. Bifidobacterium releases compounds that reduce inflammation, and so you may wish to look for a probiotic mixture containing this bacterium.

Probiotics containing live bacteria need to be stored in the fridge. Any probiotic that contains lactobacillus is derived from milk, and so many not be suitable for those with severe dairy intolerances.

Nutritional treatment

If you have Crohn’s, a special liquid diet taken by mouth or given via a feeding tube (enteral nutrition) or nutrients injected into a vein (parenteral nutrition) may be recommended. This can improve your overall strength and nutrition, and allow the bowel to rest, which can reduce inflammation. For more information about nutritional therapy, see our guide on food.

Side effects of PPIs can include headache, diarrhoea, stomach pain, rashes, and swollen feet. More rarely, they can cause kidney problems or agranulocytosis, which is a lack of white blood cells. Proton-pump inhibitors may not be suitable if you are also taking the immunosuppressants methotrexate or tacrolimus, and are also not recommended for people with Microscopic Colitis - a form of Inflammatory Bowel Disease, different from Ulcerative Colitis or Crohn’s Disease, that affects the large bowel.

White blood cells, also known as leucocytes or leukocytes, release inflammatory substances that can cause inflammation in the lining of the bowel in people with Crohn's or Colitis. Adacolumn treatment involves taking blood from the body, passing the blood through a device to remove specific white blood cells called granulocytes, monocytes and macrophages, and then returning the blood to the body.

Adacolumn treatment is usually given as an outpatient or in a day clinic. Blood is taken from a vein in one arm by inserting a cannula or needle into the vein. The blood is pumped slowly through the device, which consists of a plastic cylinder with small beads of cellulose acetate inside it. Some types of leukocytes are selectively removed by the cellulose acetate as the blood passes through the cylinder, so fewer of these white blood cells are available to move to the bowel wall and fuel inflammation. After passing through the Adacolumn, blood is returned to the body through a vein in the opposite arm.

A drug called heparin is given during the treatment to make the blood slightly thinner, to avoid clogging up the adsorption device. Each treatment session lasts about one hour. Sessions may take place once weekly for five weeks, although the doctor may decide to use a different treatment regimen. The outcome is usually evaluated twelve weeks after starting treatment.

Adacolumn works in a different way from drug treatment, so tends to have fewer side effects. The most common side effects reported are headaches, dizziness and flushing of the cheeks.

This treatment is more commonly used in patients with Ulcerative Colitis, because there has been more research into its effectiveness in Colitis than in Crohn’s. Adacolumn is only available in a few hospitals in the UK at present. Your IBD team might be able to make a referral if you would like to be considered for this treatment. Some studies have found Adacolumn to be effective in bringing about remission, but more research is needed.