IBD Therapies Guide

Adalimumab
Database
Anti-TNF: Neutralizes TNF-α to block pro-inflammatory signaling.
Indication
Induction
Maintenance
Inflammatory Bowel Disease
SC: 160 mg at week 0, 80 mg at week 2
SC: 40 mg every 2 weeks starting at week 4
Sources:EMA
Azathioprine
Database
Thiopurine: Interferes with purine synthesis to reduce lymphocyte proliferation and inflammation.
Indication
Induction
Maintenance
Inflammatory Bowel Disease
Not used for induction.
PO: 2-2.5 mg/kg once daily

Notes

  • Check TPMT and NUDT15.
  • Monitor FBC & LFTs: weeks 2, 4, 8, 12; then q3 months once stable.
  • Target 6-TGN: 235-450 pmol/8×10⁸ RBCs (↑ = myelotoxicity).
  • Target MMP: <5700 pmol/8×10⁸ RBCs (↑ = hepatotoxicity).
  • Low 6-TGN + Low/Normal MMP: suggests poor adherence/subtherapeutic; ↑ dose 25-33%, recheck in 4 weeks.
  • Low 6-TGN + High MMP (MMP:TGN >11): hypermethylator (↑TPMT activity); ↓ dose to 25-33% of original, add allopurinol 100 mg/day, recheck in 4 wks.
Sources:EMABSG 2025ESPGHAN UC 2025ESPGHAN CD 2020
Etrasimod
Database
S1P receptor modulator: Traps lymphocytes in lymph nodes to reduce gut infiltration.
Indication
Induction
Maintenance
Ulcerative Colitis
PO: 2 mg once daily
PO: 2 mg once daily

Notes

  • Obtain an ECG before treatment.
  • Caution with beta-blockers / QT-prolonging drugs
  • Monitor first dose in patients with resting HR <50 bpm, second-degree Mobitz I AV block, or a history of myocardial infarction/heart failure: Hourly pulse and blood pressure for at least 4 hours.
  • Monitor FBC and LFTs.
  • Contraindicated in pregnancy.
Sources:EMA
Filgotinib
Database
JAK inhibitor: Blocks Janus kinase signaling to reduce cytokine-driven immune activation.
Indication
Induction
Maintenance
Ulcerative Colitis
PO: 200 mg once daily for 10 weeks
PO: 200 mg once daily*

Notes

  • Induction may be extended up to 22 weeks.
  • Discontinue if no response by week 22.
  • Monitor FBC, LFTs, and lipids.
  • *100mg once daily if age ≥65 years or CrCl 15-60 mL/min
  • Not recommended in patients ≥75 years.
  • Contraindicated in pregnancy.
Sources:EMA
Golimumab
Database
Anti-TNF: Neutralizes TNF-α to block pro-inflammatory signaling.
Indication
Induction
Maintenance
Ulcerative Colitis
SC: 200 mg at week 0, 100 mg at week 2
SC: 50 mg every 4 weeks if <80 kg beginning at week 6; 100 mg every 4 weeks if ≥80 kg

Notes

  • Consider discontinuation if no evidence of benefit by week 14.
Sources:EMA
Guselkumab
Database
Anti-IL23: Selectively blocks IL-23 to limit Th17-mediated inflammation.
Indication
Induction
Maintenance
Ulcerative Colitis
IV: 200 mg at weeks 0, 4, and 8
SC: 100 mg every 8 weeks from week 16 or 200mg every 4 weeks from week 12
Crohn's Disease
IV: 200 mg at weeks 0, 4, and 8
SC: 400 mg at weeks 0, 4, and 8
SC: 100 mg every 8 weeks from week 16 or 200mg every 4 weeks from week 12

Notes

  • Consider discontinuation if no evidence of benefit by week 24.
  • Monitor LFTs.
Sources:EMA
Infliximab
Database
Anti-TNF: Neutralizes TNF-α to block pro-inflammatory signaling.
Indication
Induction
Maintenance
Inflammatory Bowel Disease
IV: 5 mg/kg at weeks 0, 2, and 6
IV: 5 mg/kg every 8 weeks starting at week 14
SC: 120 mg every 2 weeks starting at week 10

Variants

Acute Severe Colitis

Accelerated induction (3 doses within 24 days, for example at week 0, 1 and 2) with 5-10 mg/kg. [BSG 2025; Low-Quality Evidence]

Notes

  • Therapeutic drug monitoring may alter dosage/intervals.
  • Consider combination therapy with immunomodulator such as azathioprine (clinical trial data/guideline recommendation).
  • Specifically licensed for fistulising Crohn's disease.
Sources:EMABSG 2025
Mercaptopurine
Database
Thiopurine: Interferes with purine synthesis to reduce lymphocyte proliferation and inflammation.
Indication
Induction
Maintenance
Inflammatory Bowel Disease
Not used for induction.
PO: 1-1.5 mg/kg once daily

Notes

  • Check TPMT and NUDT15.
  • Monitor FBC & LFTs: weeks 2, 4, 8, 12; then q3 months once stable.
  • Target 6-TGN: 235-450 pmol/8×10⁸ RBCs (↑ = myelotoxicity).
  • Target MMP: <5700 pmol/8×10⁸ RBCs (↑ = hepatotoxicity).
  • Low 6-TGN + Low/Normal MMP: suggests poor adherence/subtherapeutic; ↑ dose 25-33%, recheck in 4 weeks.
  • Low 6-TGN + High MMP (MMP:TGN >11): hypermethylator (↑TPMT activity); ↓ dose to 25-33% of original, add allopurinol 100 mg/day, recheck in 4 wks.
Sources:EMABSG 2025ESPGHAN UC 2025ESPGHAN CD 2020
Mesalazine
Database
5-Aminosalicylic Acid: Acts locally in the gut to reduce inflammation via COX and NF-κB inhibition.
Indication
Induction
Maintenance
Ulcerative Colitis
PO: ≥2 g/day up to 4.8 g/day
PR: ≥1 g/day
PO: ≥2 g/day
PR: ≥1 g/day

Notes

  • Mesalazine not recommnended for Crohn's disease.
  • Topical therapy (suppositories/enemas) can be used for proctitis or left-sided colitis.
Sources:EMA
Methotrexate
Database
Antimetabolite: Inhibits nucleotide synthesis to limit immune cell proliferation.
Indication
Induction
Maintenance
Inflammatory Bowel Disease
IM: 25 mg once weekly*
IM: 15 mg once weekly

Notes

  • Rarely used for induction alone.
  • Monitor FBC, U&E and LFTs every 1-2 weeks until stable, thereafter every 2-3 months.
  • Be aware of significant side effects including marrow suppression, GI/liver/lung toxicity.
  • Consider folic acid supplementation to reduce side effects.
  • Contraindicated in pregnancy.
  • EMA Alert: Ensure patients remember dosing is once a week only. Serious side effects and fatalities have occurred due to accidental overdosing.
Sources:EMA
Mirikizumab
Database
Anti-IL23: Selectively blocks IL-23 to limit Th17-mediated inflammation.
Indication
Induction
Maintenance
Ulcerative Colitis
IV: 300 mg at weeks 0, 4, and 8*
SC: 200 mg every 4 weeks
Crohn's Disease
IV: 900 mg at weeks 0, 4, and 8
SC: 300 mg every 4 weeks

Notes

  • *For ulcerative colitis, extended induction can be considered with 300mg IV at weeks 12, 16 and 20.
  • Consider discontinuation if no evidence of benefit by week 24.
  • Monitor LFTs.
Sources:EMA
Ozanimod
Database
S1P receptor modulator: Traps lymphocytes in lymph nodes to reduce gut infiltration.
Indication
Induction
Maintenance
Ulcerative Colitis
PO: Days 1-4: 0.23 mg once daily; Days 5-7: 0.46 mg once daily; Thereafter: 0.92 mg once daily
PO: 0.92 mg once daily

Notes

  • Obtain an ECG before treatment.
  • Caution with beta-blockers / QT-prolonging drugs
  • Monitor first dose in patients with resting HR <55 bpm, second-degree Mobitz I AV block, or a history of myocardial infarction/heart failure: Hourly pulse and blood pressure for at least 6 hours + ECG at 0 and 6 hours.
  • Monitor FBC and LFTs.
  • Advise sun protection to reduce risk of non-melanoma skin cancers.
  • Contraindicated in pregnancy.
Sources:EMA
Risankizumab
Database
Anti-IL23: Selectively blocks IL-23 to limit Th17-mediated inflammation.
Indication
Induction
Maintenance
Ulcerative Colitis
IV: 1200 mg at weeks 0, 4, and 8
SC: 180 mg or 360 mg every 8 weeks from week 12
Crohn's Disease
IV: 600 mg at weeks 0, 4, and 8
SC: 180mg or 360 mg every 8 weeks from week 12

Notes

  • Consider discontinuation if no evidence of benefit by week 24.
  • Monitor LFTs.
Sources:EMAFDA
Steroids
Database
corticosteroids
Indication
Induction
Maintenance
Inflammatory Bowel Disease
PO: Prednisolone 40mg once daily tapering by 5mg/week over 8 weeks
IV: Methylprednisolone 30mg twice daily or Hydrocortisone 100mg four times daily
Avoid long-term use.

Variants

Budesonide MMX

Budesonide MMX 9 mg once daily for 8 weeks for:

  1. Induction of remission in mild/moderate UC where 5-ASA fails/not tolerated, and wish to avoid more potent systemic corticosteroids.
  2. Induction of remission in patients with mild ileocaecal Crohn's Disease for not more than 12 weeks.

Beclomethasone dipropionate

5 mg once daily for 4 weeks for induction of remission in UC where 5-ASA fails/not tolerated, and wish to avoid more potent systemic corticosteroids.

Topical steroids for proctitis

Budesonide (foam may be better tolerated than enemas):

  • Foam 1 application (2mg)/day for up to 8 weeks.
  • Suppository 4mg/day for up to 8 weeks.
  • Enema 1 application/day for 4 weeks.

Prednisolone:

  1. Suppositories 5mg twice daily (No clear duration recommendation, may be continued for some months if good response)
  2. Foam 20-40 mg once daily for 2 weeks initially extendable up to 4 weeks.

Notes

  • Consider adding bone protection (calcium/vitamin D).
  • Consider DEXA scan if on steroids >3 months.
Sources:BSG 2025ESPGHAN UC 2025ESPGHAN CD 2020
Tofacitinib
Database
JAK inhibitor: Blocks Janus kinase signaling to reduce cytokine-driven immune activation.
Indication
Induction
Maintenance
Ulcerative Colitis
PO: 10 mg twice daily for 8 weeks
PO: 5 mg twice daily*

Notes

  • Monitor FBC, LFTs, and lipids.
  • Induction may be extended to 16 weeks if response at week 8 is inadequate.
  • Discontinue if no response by week 16.
  • *10 mg orally twice daily may be considered if response decreases on 5 mg twice daily
  • *10 mg twice daily for maintenance treatment is not recommended in patients with known venous thromboembolism, major adverse cardiovascular events and malignancy risk factors, unless there is no suitable alternative treatment available.
  • *10 mg twice daily for maintenance should be used for the shortest duration possible.
  • Contraindicated in pregnancy.
Sources:EMA
Upadacitinib
Database
JAK inhibitor: Blocks Janus kinase signaling to reduce cytokine-driven immune activation.
Indication
Induction
Maintenance
Ulcerative Colitis
PO: 45 mg once daily for 8 weeks**
PO: 15-30 mg once daily #
Crohn's Disease
PO: 45 mg once daily for 12 weeks*
PO: 15-30 mg once daily #

Notes

  • *Ulcerative colitis: Prolonged induction up to further 8 weeks. Discontinue if no response by week 16.
  • **Crohn's disease: Prolonged induction at 30 mg once daily up to further 12 weeks. Discontinue if no response by week 24.
  • # Recommended maintenance dose is 15 mg once daily if age ≥65
  • Monitor FBC, LFTs, and lipids.
  • Caution in venous thromboembolism, cardiovascular disease, and malignancy risk factors.
  • Contraindicated in pregnancy.
Sources:EMA
Ustekinumab
Database
Anti-IL12/23: Inhibits shared p40 subunit to reduce Th1 and Th17 immune responses.
Indication
Induction
Maintenance
Inflammatory Bowel Disease
IV: <55 kg: 260 mg; 55-85 kg: 390 mg; >85 kg: 520 mg
SC: 90 mg every 8-12 weeks starting at week 8

Notes

  • Dosing frequency may be increased to every 8 weeks based on clinical response.
  • Consider discontinuation if no evidence of benefit by week 16.
Sources:EMA
Vedolizumab
Database
Anti-integrin: Blocks leukocyte adhesion and trafficking into gut tissue.
Indication
Induction
Maintenance
Inflammatory Bowel Disease
IV: 300 mg at weeks 0, 2, and 6
IV: 300 mg every 8 weeks
SC: 108 mg every 2 weeks

Variants

Pouchitis

Vedolizumab is licensed for the treatment of pouchitis in patients with inadequate response to antibiotic therapy. The induction and maintenance regimen is the same as above. Treatment should be started in parallel with antibiotics, and discontinued if there is no clinical response by week 14.

Notes

  • For Crohn's disease, optional 300 mg IV at week 10 if no response by week 6.
Sources:EMA
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