Treatment options for ulcerative colitis include everything from anti-inflammatory suppositories to the highest-tech monoclonal antibodies, and from oral steroids to surgery. Fortunately, for many people combination therapy is effective in restoring a normal rhythm to daily life.
UC Treatment Basics
Diagnosis identifies the location of the UC and its severity, and that determines the initial treatment choices. But the way the disease affects a person may evolve over time. "UC can change its location and spread up the colon and back down," explains David Sachar, M.D., a gastroenterologist at Mount Sinai Medical Center in New York City and coauthor of the American College of Gastroenterology Ulcerative Colitis Practice Guidelines in Adults. "But almost all cases start near the rectum, so you begin therapy with a topical treatment. Then if you combine oral and topical treatmentslike wearing suspenders and a beltyou are covered both ways," he says.
For mild to moderate distal UC (Distal means that it is located below the splenic flexure—a sharp bend between the transverse and the descending colon—and reachable with topical therapies.)
- Oral aminosalicylates
- Topical mesalamine
- Topical steroids
The American College of Gastroenterology states that topical mesalamine agents are superior to topical steroids or oral aminosalicylates, and a combination of oral and topical aminosalicylates is more effective than either alone. People who don’t respond to any combination of these drugs may need to take oral steroids.
For treatment during remission of distal UC
- Mesalamine suppositories in those with proctitis (UC limited to the rectum)
- Mesalamine enemas for those with distal colitis
- Aminosalicylates (sulfasalazine, mesalamine and balsalazine)
For mild to moderate extensive UC/active
- Oral sulfasalazine or alternative aminosalicylate (sometimes with topicals)
- Oral steroids only when other therapies fail or patient is in need of very rapid curbing of symptoms
- 6-MP (6-mercaptopurine) or azathioprine, when prednisone (steroid) doesn’t work
For treatment during remission of mild to moderate extensive UC
- Sulfasalazine, olsalazine, mesalamine and balsalazine
- Azathioprine or 6-MP, if aminosalicylates don’t work or patient is dependent on steroids
For management of severe colitis
If a person isn’t responding to oral treatment with prednisone, aminosalicylates and topical medications, the doctor should exclude digestive upset from C. difficile or any other gastrointestinal infection. Medications and procedures recommended include:
- Intravenous steroids
- Intravenous cyclosporine
- Surgery (colectomy—removal of all or part of the large intestine)
“Let’s keep our eye on what the ultimate goal of therapy is—and it is not avoidance of surgery. It is to make the patients well and get them back into their lives,” explains Dr. Sachar. “In many cases the potions and pills do a good job, but if they don’t, it is crazy to keep the patient from having surgery. Surgery is an excellent treatment option and turns out to be the best choice for many patients with ulcerative colitis.”
New UC Therapies
“One significant change in treatment,” says Dr. Sachar, “is the use of an anti-tumor necrosis factor (TNF) agent called infliximab, a monoclonal antibody that reduces inflammation in the intestines and tamps down the over-exuberant immune system that appears to be at the heart of the condition.”
For moderate UC, this anti-TNF medication seems beneficial. Regrettably, however, in about half of the cases, infliximab seems to lose its effectiveness as the body starts to make antibodies against it.
"Fortunately," says Dr. Sachar, "there are techniques for inhibiting the formation of these antibodies—for example, by giving a big dose of the anti-TNF agent up front and then giving doses of it at regular intervals. Also, giving an immunosuppressive agent along with the anti-TNF drug may overcome the gradual decline in the drug’s effectiveness."
Another improvement in UC therapy arrived recently with the development of pills containing larger doses of mesalamine, the aminosalicylate in sulfasalazine. This reduces the total number of pills that a patient may need to take in a day—and helps diminish the likelihood that someone would skip a dose or two and suffer loss of control.
"After all, none of the medication works if it stays in the bottle," says Dr. Sachar.
Which form of mesalamine your doctor prescribes for you depends on where your colitis is active and how you react to the drug.
Source: American Journal of Gastroenterology, July 2004.