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, methylprednisolone and budesonide) 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. Budesonide tends to cause fewer steroid side-effects than prednisone.
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. There are two classes of biologic agents that are approved for use in UC. The first class of medications works on an inflammatory molecule called tumor necrosis factor alpha (TNF-alpha) and is commonly called anti-TNF agents. Anti-TNF drugs approved for the treatment of ulcerative colitis include infliximab, adalimumab, and golimumab. Infliximab is administered by IV infusion generally every eight weeks while adalimumab is a subcutaneous injection every two weeks and golimumab is a subcutaneous injection every four weeks. Side effects of these medications include infusion or injection site reactions and allergic hypersensitivity reactions. There are rare risks of serious infections with these medications. These medications lower one’s immune system response so your doctor should perform a skin test or blood test for latent tuberculosis and a blood test for hepatitis B before starting a biologic drug. Lymphoma is a rare risk of these therapies. Combination therapy with azathioprine/6-mercaptopurine and biologics increases the risk of a particularly rare type of lymphoma called hepatosplenic T-cell lymphoma. The second class of biologic medications, called integrin inhibitors, works on receptors called integrins, which control the trafficking of white blood cells to the intestine. The only currently approved integrin inhibitor for ulcerative colitis is called vedolizumab, which is administered as an IV infusion every eight weeks. Side effects include infusion reactions, increased susceptibility to infections, and slightly increased risk of lymphoma or other malignancies. 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 to 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.
What is the role of surgery?
Surgery in ulcerative colitis is performed for a number of reasons and is generally considered to be curative if the entire large intestine is removed. Patients who do not respond to medications, are concerned about or have unacceptable side effects from medications, develop toxic megacolon, dysplasia (precancerous lesions) or cancer, or are children who are not growing because of UC are often considered for surgery. Several different surgeries are performed for UC and the choice of surgery is dependent on patient preference and the experience of the surgeon. The most common surgery is total proctocolectomy with ileal pouch anal anastomosis (total removal of the colon and rectum with creation of a pseudo-rectum from a portion of the small intestine). This operation usually requires two separate surgeries to be completed, although it may require three stages in severely ill patients. Following this surgery, patients can expect 5-10 stools daily, as they no longer have a colon to store stool. Patients usually feel better because their sense of stool urgency improves, they no longer have bleeding, and their medications can often be stopped. However, these patients are at risk for post-operative inflammation of the pouch known as pouchitis, which is usually treated with antibiotics. Women who have this surgery may have decreased ability to get pregnant naturally.
Another common surgical procedure involves a proctocolectomy with ileostomy (removal of the entire colon and rectum, and connection of the small intestine to the abdominal wall so that stool empties into a bag). This procedure is often undertaken in elderly patients, obese patients or those with anal dysfunction. Should you need a surgical procedure for UC, your surgeon can help you decide which type of surgery best fits your needs.
Do complementary and alternative therapies work in UC?
Outside of the standard medical therapies discussed for ulcerative colitis, many alternative therapies have been studied. No studies have suggested that diet can either cause or treat UC and there is no specific diet that patients with UC should follow, though it is advisable to eat a balanced diet. Likewise, there is no convincing evidence that UC results from food allergies. Though vitamin and mineral deficiencies are more common in Crohn’s disease, specific deficiencies can occur in UC patients. For this reason, a multivitamin and a calcium supplement are not unreasonable. Malnutrition can become a concern in severe UC.
Probiotics are species of bacteria that are thought to have beneficial properties for the bowel. There are a number of scientific studies that, have been performed to assess the role of probiotics in UC, and most of these have not shown benefit. There is some evidence, however, that a specific probiotic (VSL #3) may be helpful as an additive to other therapies for maintenance of remission.
Various other herbal remedies and alternative therapies have been studied for use in patients with IBD, such as curcumin (a derivative of the herb tumeric) and parasitic worms (helminths). Though limited studies have shown promise for a number of alternative therapies, these have not yet been shown to be safe and effective, and are not currently recommended. Studies of homeopathic compounds are currently ongoing and will hopefully provide novel treatments for use in UC in the future.
What type of follow-up is required?
As mentioned earlier, ulcerative colitis is a chronic disease, and establishing a long-term relationship with a gastroenterologist experienced in the treatment of UC is advisable. Many medications used in UC require regular blood work to ensure that they are not causing any serious side effects. Patients with UC have a higher risk of osteoporosis associated with both underlying disease activity and long-term or frequent steroid use. Because of this risk, doctors may recommend measurement of vitamin D blood levels and a bone mineral density screening with a DEXA scan. Female patients on steroids or other immunosuppressive medications are more likely to have abnormal pap smears and should have regular cervical cancer screening. All patients with ulcerative colitis receiving immunomodulator or biologic therapy should have annual skin exams to screen for non-melanoma skin cancers. Immunizations are very important to prevent infection. All UC patients should receive pneumococcal and influenza vaccines. Live vaccines (such as MMR, polio, and varicella) should be avoided if your immune system is suppressed by UC medication. Colorectal cancer screening is also important because of the higher risk of cancer in patients with UC, as discussed earlier.
Where can you get more information?
Many organizations provide support and information for patients with ulcerative colitis. The ACG website (gi.org) has additional information. The Crohn’s and Colitis Foundation of America (www.ccfa.org) has extensive patient information along with links to various different social, financial, and medical support groups. Other sources of information include the individual drug company websites, and, most importantly, your personal physician.
Author(s) and Publication Date(s)
Lee Sigmon, MD and Richard Bloomfeld, MD, FACG, Wake Forest University School of Medicine, Winston-Salem NC – Updated February 2016
Sean Lynch, MD and Richard Bloomfeld, MD, Wake Forest University School of Medicine, Winston-Salem, NC – Published May 2010
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