Your pill organizer looks like a cornucopia of different medications, each with their own size, shape, and color. As a responsible IBD patient, you make sure to take them at the right time, with food or without food, firmly in line with the instructions from your doctor. You are collected, calm–you aren’t worried about possible pill interactions because you’ve done your homework, spoken to your doctor, and asked the important questions before you really needed the answer.
Great news–if this is you, you’re doing great! Instead, if you feel like you are drowning in prescriptions, then don’t worry! We spoke to international GI experts to compile this article on IBD medications and interactions to know about before you even needed to know.
What is an interaction?
Not every feeling you have on your new medication is considered an ‘interaction’. A new feeling can be attributed to introducing something unfamiliar to your body, and is not necessarily a result of an interaction with another drug. An interaction, for the purpose of this article, is defined as a reaction between two (or more) drugs taken over the same period. It must impact your body in a way that a) doesn’t happen when either drug is taken alone, and b) negatively affects your health.
Sometimes interactions between medications are synergistic, meaning they are purposefully planned to increase the efficiency of your combined treatment. In contrast, the interactions that patients and doctors alike concern themselves with are the antagonistic reactions, or the ones that negatively impact your health through interacting with each other or another chemical in your body. This chemical can be food-based, or it can be intrinsic to your body’s makeup. In either case, it requires a medical practitioner to observe the difference, and your GI will want to know about it to make sure it is not a consequence of your IBD medication or condition.
Headaches, sudden resurgence of gastrointestinal symptoms, flare-ups, joint pains, sudden mood swings, fevers, nausea, vomiting, or fatigue can all be signs of an interaction, and require a doctor to interpret if this is a temporary sign of your body adjusting to a medication, or a sign of a more severe tolerance issue.
Either way, it is important to communicate with your healthcare provider, such as your doctor, APP, nutritionist, and dietician about any new medication or supplement to make sure you avoid these negative interactions. Here are a few common interactions gastrointestinal doctors want you to know about:
IBD Medication Metabolism
Drug metabolism is both a breakdown of the medication inside your system and its transfer out of the body. For IBD patients, many of the drugs used to control the disease are metabolized by cytochrome enzymes in your liver, or the PGP transporter located along the digestive tract.
One of the most common forms of antagonistic drug interactions occurs when one drug affects the cytochrome enzymes to change the metabolic rate, or the breakdown of the other one. This impacts the period of time wherein your body is exposed to the drug, which affects its therapeutic potential.
An inducer reaction is when the new medication assists the enzymes in breaking down another drug. This means that the other drug spends less time in the body, limiting tissue exposure and may not work as well. Conversely, there are also inhibitory reactions, where the new medication inhibits the enzymes. Once inhibited, the metabolism of the other drug slows down, meaning the drug persists in your system too long or in levels too high for your body to clear. Both reactions can lead to serious harm.
Therefore, your doctor will be concerned with making sure you receive the correct dosage, as well as monitoring you for reactions between drugs or food.
Tofacitinib and Upadacitinib for IBD
Tofacitinib (Xeljanz®) and Upadacitinib (Rinvoq®) are drugs prescribed for patients with moderate-to-severe Ulcerative Colitis, with Upadacitinib also indicated for moderate-to-severe Crohn’s Disease.
These drugs undergo breakdown by a cytochrome enzyme.
If taken with an enzyme inhibitor, or a drug that increases the time that medication persists in the body, it can lead to worse immunosuppression. How does this impact IBD patients?
IBD patients experience inflammation, which is regulated by the immune system. Tofacitinib and Upadacitinib repress the normative function of our body’s defenses to the point where the inflammation is relieved, but the body can still react reasonably to threats. However, if these drugs stay in our system too long, they can work too well, and block even the helpful functions of our immune system to react to threats.
This is not limited to drug-on-drug interactions. Taking the antibiotics ciprofloxacin or clarithromycin, or even drinking grapefruit juice together with Tofacitinib or Upadacitinib increases the time that the IBD drug circulates and excessively enhances its effect. It is recommended to either avoid these other triggers or talk to your doctor about reducing the dosage of Tofacitinib/Upadacitinib when you must take these antibiotics.
The opposite also occurs. Patients taking Tofacitinib or Upadacitinib should not take Rifampicin, as this antibiotic induces, or increases, the function of the degrading enzyme. The IBD drug spends less time in the body, which means that your body doesn’t respond to your medication.
Therefore it is important to consult with your doctor when starting new medications, to make sure that you do not experience any unwanted side effects or drug-on-drug interactions.
Biologics for IBD
Biologics are drugs composed of protein antibodies (or rarely, other proteins). They are not considered ‘chemicals’ in the body in the same way that other IBD drugs are. As they are not metabolized by the cytochrome enzyme system, they lack the potential to interact with other drugs. Thus, there is generally no need to consider other medications or food items when starting a biological medication, as interactions are not an issue.
One exception is when taking other immune-suppressing drugs for IBD or other conditions– regardless if it’s a biologic or a ‘regular’ drug. In such cases, the added effect may lead to increased immune suppression, which diminishes the body’s capability to fight off threats.
Immunosuppressants for IBD
Immunosuppressants commonly prescribed for patients with IBD include S1P modulators.
S1P drugs bind to white blood cells and reduce their ability to migrate to other locations in the body. This can contribute to reducing inflammation and auto-immunity effects. However, it can also suppress the body’s natural defenses.
Ozanimod and Etrasimod are two immunosuppressants that utilize this S1P pathway to reduce inflammation. Their mechanism of action impacts not just the digestive tract but cardiac muscle, potentially lowering heart rate and blood pressure. Therefore, patients with known cardiac issues are advised to consult with a cardiologist before taking these medications.
A number of other medications impact the cardiovascular system, and therefore should be taken with caution when taking Ozanimod and Etrasimod. This is a vast group of medications ranging from SSRIs, beta blockers, anti-emetics, and even some groups of antibiotics such as macrolides and fluoroquinolones.
Ozanimod, in addition, also can interact with some psychiatric drugs to cause excessive elevation of blood pressure, and this can even happen with the consumption of tyramine-rich foods, such as hard cheeses and fermented food due to their metabolism in the body. Therefore patients should take care to avoid these foods or restrict their quantity while taking Ozanimod.
The Bottom Line: Communication, Communication, Communication
At the end of the day, everything that is broken down by your body has a specific, ideal rate at which it should be metabolized to maximize the positive effect it has on your body and reduce negative side effects. It is essential to communicate any new diets, medications, herbal supplements, or probiotics with your treating physician, so they can make sure none of the materials you are putting in your body conflict.
If you have just taken a new medication, whether it is your first or one of a hundred others you are taking, it is important to ask your doctor what to expect in terms of side effects, and report symptoms that affect your everyday life.
It’s also a good idea to have your list of medications and dosages at hand in case of a medical emergency. For instance, take a picture of your prescriptions and save it on your phone. This can then be displayed to professionals in case of a medical emergency requiring urgent treatment to make sure they know what is safe for you to take.
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Summer Pitocchelli-Schwartzman
