Ulcerative ColitisMild-moderate active UC

Moderate-to-severe active UC

Thiopurine: Azathioprine and 6-MercatopurineAnti-TNF: Infliximab (Remicade), Adalimumab (Humira)Integrin Receptor Antagonist: Vedolizumab (Entyvio)Anti-folate: Methotrexate

Formulation Sites of Action

Potential Sites of Action

Duodenum Jejunum Ileum Proximal colon Distal colon Rectum

Crohn’s only affected areas UC & Crohn’s affected areas

Pentasa ✔ ✔ ✔ ✔ ✔ ✔

Salofalk or Mesasal ? ✔ ✔ ✔ ✔

Budesonide CIR/Entocort

✔ ✔ ✔ ✔

Asacol/Mezavant/Apriso

✔ ✔ ✔ ✔

Sulfasalazine/Salazopyrin or Olsalazine

✔ ✔ ✔

5-ASA Enema or Steroid Enema

✔ ✔

5-ASA Suppository ✔

***Terminal ileum may also be affected by UC

Clinical Pearls1. pH dependent release - tablets designed to release under different pH environments

a. Separate administration with antacids, H2RA’s by at least 1 hourb. PPI: consider therapy modification (switch PPI → H2RA, or switch oral formulation 5-ASA → rectal)

2. Topical therapies achieve higher concentrations in mucosa vs. oral 3. Be cognizant of adverse reaction profile

Drug InteractionsDrug-Disease Interaction: NSAID might worsen UC/IBDDrug-Drug Interaction: 5-ASA increases myelosuppression with AZA/6-MP (TPMT inhibition)Drug-Drug Interaction: decreases digoxin bioavailability

Counselling Points1. For rectal formulations, lay on left side after insertion2. Don’t be alarmed to see undigested capsules (Asacol) 3. Don’t crush or cut tablets

● Can break Pentasa along score lines but avoid knife/pill cutter

4. Swallow tablets and capsules whole 5. Different types of formulations have slightly different

instructions regarding meals → ask your friendly pharmacist if you have any questions

6. Folic acid supplementation (1-5mg daily) for sulfasalazine

Safety profile Common adverse reactions for all formulations: nausea, vomiting, abdominal pain, headache, rash, 5-ASA increases risk of Reye’s Syndrome in patients experiencing an infectionSulfasalazine: oligospermiaOlsalazine: higher risk of diarrhea Enema: difficulty with retention, abdominal bloating, irritation upon insertion, staining, risk of perforation

Contraindications:All: salicylate hypersensitivity, existing gastric or duodenal ulcer, urinary tract obstruction, <2 years of ageSulfasalazine: hypersensitivity to sulfa-containing drugs, patients with G6PDEnema: metabisulfite sensitivity

Pharmacare Coverage

Drug Benefit Approximate cost (3 month supply)Based on usual starting maintenance dose

Pentasa Eligible benefit except for Plan G (psych patients) and plan P (palliative)

$250

Salofalk Eligible benefit except for Plan G (psych patients) and plan P (palliative)

$250

Entocort (budesonide PO and enema)

Special authority required PO: $550Enema: $6000

Asacol/Mezavant Eligible benefit except for Plan G (psych patients) and plan P (palliative)

Asacol: $200

5-ASA Enema Eligible benefit except for Plan G (psych patients) and plan P (palliative)

$500-$1000Foam is not PharmaCare formulary

5-ASA Suppositories Eligible benefit except for Plan G (psych patients) and plan P (palliative)

$200

Olsalazine Eligible benefit except for Plan G (psych patients) and plan P (palliative)

$300

Sulfasalazine Eligible benefit except for Plan G (psych patients) and plan P (palliative)

$100-200