Medical treatment of ulcerative colitis generally focuses on two separate goals: the induction of remission (making a sick person well) and the maintenance of remission (keeping a well person from getting sick again). Surgery is also a treatment option for UC and will be discussed separately. Medication choices can be grouped into four general categories: aminosalicylates, steroids, immunomodulators, and biologics.
Aminosalicylates are a group of anti-inflammatory medications (sulfasalazine, mesalamine, olsalazine, and balsalazide) used for both the induction and maintenance of remission in mild to moderate UC. These medications are available in both oral and rectal formulations and work on the lining of the colon to decrease inflammation. They are generally well tolerated. The most common side effects include nausea and rash. Rectal formulations of mesalamine (enemas and suppositories) are generally used for those patients with disease at the end of their colon.
Steroids (prednisone) are an effective medication for the induction of remission in moderate to severe UC and are available in oral, rectal, and intravenous (IV) forms. Steroids are absorbed into the bloodstream and have a number of severe side effects that make them unsuitable for chronic use to maintain remission. These side effects include cataracts, osteoporosis, mood effects, an increased susceptibility to infection, high blood pressure, weight gain, and an underactive adrenal gland.
Immunomodulators include medications such as 6-mercaptopurine and azathioprine. These are taken in pill form and absorbed into the bloodstream. They are effective for maintenance of remission in moderate to severe ulcerative colitis, but are slow to work and can take up to 2-3 months to reach their peak effect. Because of this, these medications are often combined with other medications (such as steroids) in patients who are very ill. These medications require frequent blood work as they can cause liver test abnormalities and low white blood cell counts, both of which are reversible when the medication is stopped. Adverse reactions can include nausea, rash, liver and bone marrow toxicity, pancreatitis, and rarely lymphoma.
Biologic agents are medications given by injection that are used to treat moderate to severe UC. At the current time, infliximab (Remicade®) is the only biologic agent approved for use in UC, but other biologics used for Crohn's disease under evaluation for the treatment of UC include adalimumab (Humira®), and certolizumab pegol (Cimzia®). Infliximab is effective in both the induction and maintenance of remission in UC. The side effects of this medicine may include an allergic reaction to the medication called an "infusion reaction" or "hypersensitivity reaction". There are also rare risks of serious infections with these medications. Lymphoma is a rare risk of these therapies as well. Combination therapy with azathioprine/6-mercaptopurine and biologics increases the risk of a particularly rare type of lymphoma called hepatosplenic T-cell lymphoma. As with all medications, you should discuss the risks and benefits with your doctor.
Other medications used less frequently for UC include cyclosporine and tacrolimus. These agents are sometimes used in those rare cases of severe UC that are not responsive to steroids. Side effects of these agents include infections and kidney problems. These agents are offered at a limited number of hospitals and are usually used for a short period of time as a bridge to other maintenance therapies such as azathioprine or 6-mercaptopurine.
No matter which medical therapy you and your doctor decide upon, adherence with the prescribed course is essential. No medical therapy can work if it is not taken and failure to take your medications can lead to unnecessary escalation of therapy if it is not brought to the attention of your doctor. Because many of the complications associated with UC are related to ongoing disease activity, good medication adherence may minimize these risks.