Sulfasalazine Metronidazole

C. The information provided suggests the patient has mild to moderate disease. Initial therapy should be a 5-ASA containing product, which includes sulfasalazine and mesalamine. However, the patient has a sulfa allergy, precluding the use of sulfasalazine. Metronidazole is useful in the treatment of some patients with Crohn s disease. Cyclosporine has been used in patients with fulminant ulcerative colitis. Prednisone may have to be added to this patient s therapy, but only if he fails to respond to the mesalamine. It should not be used initially. 

Ampicillin and rifampicin markedly reduce the colonic release of 5-aminosalicylate (the active drug) from sulfasalazine. Metronidazole appears not to interact adversely with sulfasalazine. 

Metronidazole has been the mostly investigated agent. In 1978, Blichfeldt et al. [34] performed the first controlled study of metronidazole in CD. They did not find a difference between metronidazole and placebo-treated patients but a positive trend in favor of metronidazole was observed when the colon was involved. In the National Cooperative Swedish study, metronidazole was compared to sulfasalazine no significant difference was found between the two groups however, in the crossover section of the study, metronidazole was effective in patients not responding to sulfasalazine [35],... 

Ursing B, Aim T, Barany F, Bergelin I, Ganrot-Norlin K, Hoevels J, Huitfeldt B, Jarnerot G, Krause U, Krook A, Lindstrom B, Nordle O, Rosen A A comparative study of metronidazole and sulfasalazine for active Crohn s disease The cooperative Crohn s disease study in Sweden. II. Result. Gastroenterology I982 83 550-562. 

In the majority of patients, active Crohn s disease is treated with sulfasalazine, mesalamine derivatives, or steroids, although azathioprine, mercap-topurine, methotrexate, infliximab, and metronidazole are frequently used. 

Sulfasalazine is more effective when Crohn s disease involves the colon. Mesalamine derivatives (such as Pentasa or Asacol) that release mesalamine in the small bowel may be more effective than sulfasalazine for deal involvement. Steroids are frequently used for the treatment of active Crohn s disease, particularly with more severe presentations, or in those patients unresponsive to aminosalicylates. Budesonide is a viable first-line option for patients with mdd to moderate deal or right-sided disease. Systemic steroids induce remission in up to 70% of patients and should be reserved for patients with moderate to severe disease who have faded aminosahcylates or budesonide. Metronidazole (given orally up to 20 mg/kg/day) may be useful in some patients with Crohn s disease, particularly in patients with colonic or deocolonic involvement or those with perineal disease. The combination of metronidazole with ciprofloxacin is efficacious in some patients. 

The goal of treatment for active Crohn s disease is to achieve remission however, in many patients, reduction of symptoms so the patient may carry out normal activities, or reduction of the steroid dose required for control, is a significant accomplishment. In the majority of patients, active Crohn s disease is treated with sulfasalazine, mesalamine derivatives, or steroids, although azathioprine, mercap-topurine, methotrexate, or metronidazole are frequently used. 

Recommendations for the use of drugs in nursing mothers vary. Although prednisone and prednisolone can be detected in breast milk, breast-feeding is believed to be safe for the infant when low doses of prednisone are used. Sulfasalazine does not pose a risk of ker-nicterus, as levels of sulfapyridine in breast milk are low or undetectable. Metronidazole should not be given to nursing mothers because it is excreted into breast milk. ... 

Drug intolerance often limits the usefulness of agents used to treat IBD. Many patients receiving sulfasalazine, mesalamine, corticosteroids, metronidazole, azathioprine, mercaptopurine, or infliximab experience some undesired effects. In some cases, these adverse effects can be significant and require discontinuation of the therapy. Knowledge of the common or important adverse reactions will assist in avoiding or minimizing their effects. 

Traditional medical therapies for Crohn s disease include sulfasalazine and corticosteroids. These are pluripotent, reducing the production of inflammatory mediators and cytokines, although the complex and multiple mechanisms remain incompletely understood. Novel therapies related to newer aminosalicylate preparations such as balsalazide (colazide) or olsalazine (dipentum) newer corticosteroids such as budesonide immunomodulators such as azathioprine, 6-mercaptopurine, or methotrexate and antibiotics such as metronidazole are aimed at more specific delivery of active compounds to the site of disease, reduction of systemic absorption and side effects, and modulation of more focal targets within the immune response and the action of specific proinflammatory cytokines. 

Eradiri O, Jamali F, Thomson ABR. Interacticn of metronidazole with i enobarbital, cimetidine, prednisoie, and sulfasalazine in Qohn s disease Biopharm Drug Dispos (1988) 9,219-27. 

A study in 10 patients (7 with Crohn s disease and 5 with ulcerative colitis) taking long-term sulfasalazine 2 to 4 g daily found that no statistically significant changes in serum sulfapyridine levels occurred while they were also taking metronidazole 400 mg twice daily for 8 to 14 days. ... 

Information is limited, but the interaction appears to be established. However, the extent to which these antibacterials actually reduce the effeetive-ness of sulfasalazine in the treatment of Crohn s disease or ulcerative colitis seems not to have been assessed, but be alert for evidence of a reduced effect if ampicillin, rifampicin or any other oral antibacterial is given. Neomycin, which also affects the activity of the gut microflora, has been seen to interact similarly in animal studies, but limited evidence suggests metronidazole does not interact. 

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