Adding Meds - Immunomodulators

Quick recap of where I am.

My symptoms are close to normal, not perfect but close. My CRP sits around 5.5 and then my doc prescribes Uceris for 30 days and takes my CRP back to 1.5...two months after stopping Uceris and my CRP goes back to 5.5 and minor symptoms return. And this cycle repeats.

Current regimen
4.8g of Lialda per day
Entyvio every four weeks

Given that my inflammation comes back (albeit minor) every time I am off the Uceris for a month or two, my doc would like to add either Methotrexate or Azathioprine. She prefers Methotrexate given slightly better long term safety profile.

Now usually these immunomodulators are used with things like Remicade, limited evidence for using them with Entyvio. Also limited evidence of Methotrexate even helping with colitis (it does help with Crohn's disease).

Any thoughts? I'm a little nervous about adding even more meds on to my existing regimen.

It seems Entyvio and Lialda are doing a good job. Is your UC distal, or do you have pancolitis?
Enemas may be useful for reducing the remaining inflammation.

Why don’t you try diet in addition to your current meds? Meds alone and diet alone didn’t work for me so I’m trying both together now and I seem to be doing better (too early to tell)

Ok. That is indeed very unusual, with UC almost always starting in the rectum. Has it ever been suggested you may have Crohns?

Well, there is no way to definitively say someone has UC (there is no presentation of UC that rules out Crohn's, unlike the other way around). So, it could still be Crohn's but since the drugs are often the same I'm not sure it is something to worry about here.

MTX is probably safer, but very unlikely it will do much for UC. That said, the statement that there is little evidence for using them with Entyvio is not true. Immunomodulators are especially important with Entyvio because it does not have the systemic effect needed to control extraintestinal manifestations. I was put on MTX before even starting Entyvio because my doc wanted me on something with systemic control while on Entyvio.

If it were me, I'd start by trying a different formulation of mesalamine (probably Apriso) to see if that works. If not, I'd start looking at another biologic or adding Xeljanz at the 5mg/bid dose, if your insurance will allow it. If you aren't quite willing to commit to that, you can stay on Uceris for up to 6 months (standard minimum course is 8 weeks, per the Uceris website, not sure why they have you on 30 day courses).