Treatments for Ulcerative Colitis

By Dr. Brian Bressler

The type of treatment you might receive for ulcerative colitis depends on the severity of the symptoms, the location of the inflammation and how much of the bowel is affected. Once a diagnosis has been made, treatment protocol follows the ulcerative colitis treatment guidelines.

Because there is no cure for ulcerative colitis, treatment goals are designed to control the inflammation. Treatment is intended to put the disease into remission and to stop it from becoming active again. Remission can be defined in a few ways. The first way to define remission is when a patient’s bowel habit returns to normal, and no further blood is seen. Recent research suggests that a more reliable definition of remission is when there is no further evidence of inflammation seen in the bowel. This means to be certain a treatment has achieved remission, a physician may recommend a flexible sigmoidoscopy or colonoscopy to evaluate the colon.

Here are the established treatments for ulcerative colitis based on the severity of symptoms and their location. Depending on your unique situation, you may receive one or more of the drugs mentioned below. In more severe cases, surgery may be needed.

1. Mild to moderate left-sided (distal) colitis

For this type of colitis, the guidelines recommend three anti-inflammatory medications:

  • Oral aminosalicylates. This class of medication is effective in treating inflammation in distal colitis. It includes medications by the names: Asacol, Pentasa, Mezavant, Salofalk, and Salazopyrin
  • Topical aminosalicylates. The aminosalicylate drug mesalazine (also known as mesalamine) works directly on the affected bowel wall when given as a suppository or enema. Salofalk and Pentasa are available as both suppositories and enemas.
  • Topical steroids. Steroids, also known as corticosteroids, are used for many different conditions that involve inflammation. For topical use in ulcerative colitis, steroids are given as an enema, suppositories or foam.

Each of these medications typically works well to reduce inflammation in mild to moderate ulcerative colitis. The guidelines indicate that topical mesalazine is the most effective form of therapy when the inflammation appears only on the left side of the colon. The guidelines suggest using the combination of topical mesalazine and an oral aminosalicylate when the inflammation involves the entire colon. Although aminosalicylates tend to work quickly (improvement may occur within a few weeks), the maximum effect may take up to 2 months.

If none of these three medications is enough to control the colitis, the next step is usually an oral steroid called prednisone. Prednisone attacks inflammation throughout the body and acts as an immune suppressant. Those taking prednisone typically only stay on it for is several weeks because it is known to have unpleasant side effects. However, other options might be available, such as biologic drugs (Remicade, Simponi, Humira and Entyvio) that act to neutralize your immune system.

Maintaining remission in mild to moderate left-sided colitis

Once you achieve remission, your treatment is reassessed. The guidelines recommend both topical mesalazine (suppositories or enemas) and oral aminosalicylates for maintenance of remission because they appear to have the strongest effect on keeping the inflammation at rest. Topical steroids are not recommended. If these treatments do not keep the disease in remission, other medications such as Imuran, mercaptopurine (both of which are immune suppressants), Remicade, Simponi, Humira or Entyvio may be considered.

2. Mild to moderate extensive colitis

If the inflammation has progressed in the bowel beyond what topical medications can treat effectively, it is called extensive colitis or pancolitis (inflammation of the entire colon). The guidelines recommend treatment of extensive colitis with anti-inflammatory agents, such as oral sulfasalazine or another aminosalicylate. Topical treatment may be added if it is assessed that this combined approach could be most effective.

Maintaining remission in mild to moderate extensive colitis

Oral aminosalicylates help to reduce relapses of inflammation. Long-term steroid treatment is not safe because of the side effects. Patients who need steroids to reach or maintain a state of remission are often prescribed Remicade, Simponi, Humira, Entyvio, Imuran or mercaptopurine.

Ulcerative colitis not responding to aminosalicylates

Oral steroids (prednisone) can be used short-term if aminosalicylates fail to put the symptoms into remission or there is an acute need to provide relief from severe symptoms. Prednisone can typically be used for several weeks but must be slowly reduced thereafter. If oral steroids don’t work, Remicade, Simponi, Humira, Entyvio, Imuran or mercaptopurine can be considered. Nicotine patches may also help with symptoms of ulcerative colitis but they are not a preferred treatment over mesalamine. Nicotine patches can cause headaches in some people and this limits the use of this therapy.

3. Severe colitis

The guidelines recommend that patients who have severe symptoms and are not helped by oral or topical aminosalicylates or prednisone should be treated with one of the immune suppressants Remicade, Simponi, Humira or Entyvio. However, those with symptoms indicating toxicity, such as fever, anemia or a fast heartbeat, may have to be admitted to the hospital for treatment with intravenous steroids. If no improvement occurs within a few days, treatment with intravenous cyclosporine or Remicade can be considered. The guidelines also recommend surgery as an option to remove the affected bowel in cases of severe colitis.

If a patient with severe colitis is suspected to also have an infection, they may be given an antibiotic. Some infections, particularly a bacterium called Clostridium difficile (C. difficile), make the inflammation more difficult to treat.

Learn more about Remicade

Surgery

Surgery is sometimes necessary for patients with severe colitis. Surgery must be performed if there is severe bleeding, perforation (a hole in the intestine), or if the doctor believes there is a strong possibility of cancer in the bowel. It may also be necessary if the patient has a serious condition called toxic megacolon, where the colon swells to many times its normal size.

The most common surgery for ulcerative colitis is called an ileal pouch-anal anastomosis (IPAA). In this procedure, the large bowel is removed, and the small intestine is then joined to the anus. A temporary ileostomy (bringing the bowel to the surface of the abdomen, where it empties into an external pouch) may be needed. For some patients, the IPAA is not suitable, and a permanent ileostomy is necessary.

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