Treatment
The type of treatment that doctors use for ulcerative colitis depends on the severity of the disease and how much of the bowel is affected. Once a patient’s disease has been diagnosed and assessed, often physicians use guidelines (such as the ACG) to provide recommendations on appropriate medications and other treatments. Treatment is initially intended to put the disease into remission. Once the disease is in remission, treatment is designed to stop it 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 (to learn more about this, click here).
All of the medications used to treat ulcerative colitis can cause side effects however in general these drugs are very well tolerated. Some of these can be serious. Each patient needs to find a treatment that is tolerable and will help to control their disease,.
1. Mild to moderate left-sided (distal) colitis
For this type of colitis, the guidelines recommend three main types of medication:
- Oral aminosalicylates. This group of medications is taken by mouth. It includes Asacol, Pentasa, Mezavant, Salofalk, and Salazopyrin
- Topical aminosalicylates. The aminosalicylate drug mesalazine works directly on the affected bowel wall when it is given as a suppository, or enema. Salofalk and Pentasa both come in 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 usually works well against mild to moderate ulcerative colitis, so the patient can choose which they prefer, based on things like price, side effects or the way the drug is taken.. The guidelines point out that topical mesalazine is the most effective form of therapy when the inflammation is only involving the left side of the colon, so this should be kept in mind. The guidelines also suggest using topical mesalazine and an oral aminosalicylate together if a stronger effect is needed when the inflammation is involving the entire colon.
Though aminosalicylates can work fairly quickly (improvement maybe seen within a few weeks), they may take up to 2 months for their maximum effect to be noticed.
If none of these three medications is enough to control the colitis, the next step is usually an oral steroid called prednisone. However other options such as Remicade, Humira or Simponi can be considered as well.
Maintaining remission in mild to moderate left-sided colitis
Once the patient achieves remission, their treatment is reassessed. The guidelines recommend both topical mesalamine and oral aminosalicylates for the maintenance of remission. As with the initial treatment, using topical mesalamine and an oral aminosalicylate together has a stronger effect. Topical steroids are not recommended, as they do not work well to maintain remission. The most effective treatment in remission is to use mesalamine suppositories or enemas, which may only be needed every three days. If these treatments do not keep the disease in remission, othe medications such as Imuran, mercaptopurine, Humira, Remicade, or Simponi maybe considered.
2. Mild to moderate extensive colitis
If the colitis is too far along the bowel for topical medicines to reach, it is called extensive colitis or pancolitis. The ACG guidelines recommend treatment of extensive colitis with oral sulfasalazine or another aminosalicylate. Topical treatment may be added as well as this combined approach seems to be most effective.
Maintaining remission in mild to moderate extensive colitis
Oral aminosalicylates help to reduce relapses of colitis. Long-term steroid treatment is not safe. Patients who needed steroids to reach remission are switched to Humira, Remicade, Simponi, Imuran or mercaptopurine.
Ulcerative colitis not responding to aminosalicylates
Oral steroids (prednisone) can be used if aminosalicylates don’t put the disease into remission. They can also be given at first, if the patient is suffering a lot from symptoms and needs to improve quickly. The typical use of prednisone involves starting at a high dose for 2-4 weeks, It can take up to 2 weeks before the benefits of prednisone are seen. After this relatively brief exposure to prednisone it is important that the medication be slowly reduced. By 12 weeks patients should be off steroids. If this is not possible because of symptoms further medications maybe added to reach this important goal of therapy. If oral steroids don’t work, Humira, Remicade, Simponi, Imuran or mercaptopurine can be considered. Nicotine patches can help patients with ulcerative colitis, and are sometimes used, but they are no better than mesalamine. The tolerability of nicotine patches (in particular headaches) limits the use of this therapy.
3. Severe colitis
The ACG guidelines recommend that patients who have severe symptoms that are not helped by oral or topical aminosalicylates or prednisone should be treated with Remicade. Research that has been published since the ACG guidelines were published supports the use of Humira or Simponi in this situation as well. However, patients who have symptoms of toxicity, such as fever, anemia or a fast heartbeat, may have to be admitted to hospital for treatment with intravenous steroids. If they do not improve in a few days, treatment with intravenous cyclosporine or Remicade can be considered. The guidelines also recommend surgery to remove the affected bowel as an option in severe colitis.
If a patient with severe colitis is suspected to also have an infection, they may be given an antibiotic, as some infections, particularly by a bacterium called Clostridium difficile (C. difficile), make the colitis more difficult to treat.
Surgery
Surgery is sometimes necessary for patients with severe colitis. Surgery must be performed if the patient has severe bleeding, perforation (a hole through the gut wall into the abdomen), or if the doctor believes there is a strong chance of cancer in the bowel. It may also be necessary if the patient has a condition called toxic megacolon, in which the space inside the bowel becomes larger than normal. Surgery is also an option if even the strongest medications do not help the patient, or if the side effects are too much for the patient to tolerate.
The most common surgery is called an ileal pouch-anal anastomosis (IPAA). 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 ileostomy bag) may be needed. For some patients, the IPAA is not suitable, and a permanent ileostomy is necessary.