Prescribing Inflammatory Bowel Disease Medications in Chronic Kidney Disease: A Practical Guide

Abstract

Background: The prevalence of chronic kidney disease (CKD) in patients with inflammatory bowel disease (IBD) is increasing. The pharmacokinetic profiles of IBD medications in patients with advanced-stage CKD are not well studied.

Aim: To provide evidence-based guidance on the use of medical therapies in patients with IBD and CKD.

Methods: We conducted a narrative review of literature up to 31 March 2025 on studies of therapies currently used for the treatment of IBD in the setting of CKD, with a focus on advanced kidney disease and use in renal replacement therapy.

Results: Mesalazine can cause acute interstitial nephritis. Calcineurin inhibitors have been associated with nephrotoxicity. Methotrexate is contraindicated in advanced renal disease, including while on renal replacement therapy, due to higher risks of toxicity and myelosuppression. Dose adjustment of thiopurines should be considered in advanced renal disease due to metabolite accumulation. Monoclonal antibodies, including anti-tumour necrosis factor therapy, anti-integrin therapy and anti-interleukin 12/23 therapies, appear to be safe in renal insufficiency, including haemodialysis. There is limited data available for small molecule therapies; drug metabolism profiles suggest they are safe in CKD, although, for Janus kinase (JAK) inhibitors, including tofacitinib and upadacitinib, dose reduction should be considered in advanced renal disease.

Conclusion: Most therapies used in IBD, particularly biologic therapies, appear safe and effective when used in patients with CKD, including those on renal replacement therapy. Caution should be considered when using conventional therapies and JAK inhibitors.

Keywords: Crohn's disease; chronic kidney disease; dialysis; ulcerative colitis.

FIGURE 1

Renal excretion at the nephron. Renal excretion in the nephron begins with filtration, whereby a capillary bed known as the glomerulus is in contact with the Bowman's capsule of the nephron. Filtration of drugs occurs via fenestrations within Bowman's capsule, whereby small molecules can travel freely into Bowman's space. Drugs that are sufficiently small can also be filtered to variable degrees based on whether they are positively charged (filters more) or negatively charged (filters less, given the negative charge of Bowman's capsule). Larger molecules, such as monoclonal antibodies and protein‐bound drugs, are unable to be filtered and do not enter the glomerulus. Within the tubules of the nephron, exchange of a drug can occur via tubular secretion (facilitating excretion) and tubular reabsorption (reduced renal excretion); renal impairment is unlikely to impact clinically meaningful secretion or reabsorption in the IBD medicines discussed in this review.