0521779407-C04 CUNY1086/Karliner 0 521 77940 7 June 14, 2007 20:37
422 Crohn’s Disease■abnormal sperm count, motility and morphology occur commonly
with sulfasalazine (and not mesalamine) but are reversible with dis-
continuation of medication
■low-grade hemolysis on sulfasalazine is not unusual, but is rarely
severe
■sulfasalazine may interfere with folic acid absorption
■side effects of mesalamine: hair loss, rarely interstitial nephritis (may
be irreversible)
■antibiotics: metronidazole or ciprofloxacin
■side effects of metronidazole: nausea, diarrhea, metallic taste,
peripheral neuropathies (may be irreversible), monilial infections,
teratogenic, ?cancer risk
■side effects of ciprofloxacin: diarrhea, teratogenicModerate to Severe Disease
■Add azathioprine (Aza) or 6-mercaptopurine (6MP) – start at a low
dose (50 mg/d) and slowly increase the dose by adding not more than
25 mg each month until 2.5 mg/kg/day for Aza or 1.5 mg/kg/day for
6MP or until leukopenia or elevated LFTs, whichever occurs first.
Check CBC and LFTs every 2 weeks when starting or increasing the
dose and every 3 months when on a stable dose. If TPMT enzyme
activity is checked initially and is normal, then one can start at a
higher dose and increase the dose at a faster rate to achieve earlier
effect.
➣side effects of Aza or 6MP: fatigue, nausea, bone marrow depres-
sion, opportunistic infections, pancreatitis, hepatitis, fever,
rarely lymphoma
■Methotrexate if intolerant to Aza or 6MP. Induction dose: 25 mg i.m.
weekly for 16 weeks. Maintenance dose: 15 mg i.m. weekly
➣side effects of methotrexate: fatigue, nausea, diarrhea, leukope-
nia, opportunistic infections, liver disease
■consider adding a TNF blocker if Aza, 6MP or methotrexate fails to
hold the disease in remission. TNF blockers will be more effective if
pt is on concomitant Aza, 6MP or methotrexate. Caution: Therapy
with double or triple immunomodulators increases the risk for life-
threatening infections.
➣side effects of TNF blockers: infusion reactions, infections,
immune response, lymphoma
Active disease:
■oral corticosteroids (occasionally)