Ulcerative Colitis Treatment

Ulcerative colitis  is a condition of long-term (chronic) inflammation of the large intestine (colon). Symptoms of ulcerative colitis are rectal bleeding, diarrhea, and abdominal pain.¹ People with ulcerative colitis alternate between having active disease (when symptoms flare up) and disease-free periods (remission). The goals of treatment are to relieve symptoms, enter remission, and stay in remission.¹

With ulcerative colitis, each person’s disease is different. Therefore, treatment is different for every patient. The best treatment depends on what section of the intestine is inflamed and how severe the inflammation is.¹ Treatment for ulcerative colitis may include medication, surgery, and symptom management. Although diet does not cause ulcerative colitis, some diet changes might reduce symptoms.²

Medications

There are four categories of medications used to treat ulcerative colitis (Table).²

• Aminosalicylates
• Corticosteroids
• Immunomodulators
• Biologics

Aminosalicylates: These medications reduce inflammation.² They are commonly used to treat mild to moderate ulcerative colitis. They treat active disease and maintain remission.

Some aminosalicylate medications are topical, which means they are taken as a suppository or enema.^1,2 Taking the medication this way helps it get right to the inflamed area. For an enema or rectal foam, a medication solution is injected into the large intestine via the rectum. A suppository is a solid medication that is inserted into the rectum, where it dissolves. Other aminosalicylates come as pills or tablets that are taken by mouth. Oral and topical aminosalicylates can be used together when needed.^1,2

Aminosalicylate medications used to treat ulcerative colitis are:³

• Sulfasalazine (brand name: Azulfidine)
• Mesalamine (brand names: Asacol, Pentasa, Apriso, Lialda, Delzicol, Rowasa, Canasa)
• Balsalazide (brand names: Giazo, Colazal)
• Olsalazine (brand name: Dipentum)

Corticosteroids:These medications also reduce inflammation. They are sometimes used for a short period of time when aminosalicylates are not enough.¹ Because corticosteroids make the whole immune system less active, they have many side effects.⁴ Therefore, corticosteroids are not usually used for long-term treatment or to keep you in remission. Corticosteroids can be taken by mouth, topically, or intravenously.⁵ Examples of corticosteroids used for ulcerative colitis are:^3,5

• Prednisone
• Methylprednisolone (brand name: Solu-Medrol)
• Hydrocortisone (brand names: Proctofoam, Cortenema)
• Budesonide (brand name: Uceris)

Immunomodulators:These medications weaken the immune system, which reduces ongoing inflammation.⁶Immunomodulators can take up to 3 months to start working.² Therefore, they may be used with a medication that works more quickly, such as a corticosteroid. A health care provider may prescribe an immunomodulator for patients whose disease does not improve with other medications. They are sometimes used for patients who are taking high doses of corticosteroids, so that the corticosteroid dose can be lowered. Immunomodulators used to treat ulcerative colitis are:^3,6

• Azathioprine (brand name: Imuran)
• 6-mercaptopurine (6-MP) (brand name: Purinethol)
• Cyclosporine (brand name: Gengraf, Neoral, Sandimmune)
• Tacrolimus (brand name: Prograf)

Biologics: Biologic therapies are relatively new treatments for ulcerative colitis. Biologic medications for ulcerative colitis come from specially engineered proteins made by living cells in a laboratory.⁴ These medications target certain cells and processes involved in inflammation. Biologic medications are usually used for people with moderate or severe disease when other treatments have not worked. They may help you to enter remission and stay in remission. Some of these medications are taken by an injection under the skin; this can be done at home. Others are taking intravenously (in the vein) and must be given by a healthcare provider. Biologics used to treat ulcerative colitis are:²

• Infliximab (brand name: Remicade)
• Vedolizumab (brand name: Entyvio)
• Adalimumab (brand name: Humira)
• Golimumab (brand name: Simponi)

Symptom management

Some people with ulcerative colitis use medications to relieve symptoms.^2,3 Importantly, medications for symptoms relief should not be used in place of ulcerative colitis medications. Medications that reduce inflammation are needed to treat the underlying disease. If your symptoms linger even though you are taking ulcerative colitis medications, ask your health care provider about using:

• Anti-diarrheal medications (loperamide/Imodium or Lomotil)
• Anti-gas medications
• Acetaminophen for pain relief
• Antibiotics to treat infections

Some over-the-counter pain relievers, such as ibuprofen and aspirin (also known as NSAIDS), are not recommended for people with inflammatory bowel disease.² NSAIDs may worsen your intestinal symptoms.

Surgery

Many people are able to manage their ulcerative colitis with medications. Yet one-quarter to one-third of people with ulcerative colitis may need to have surgery.³

Sometimes surgery is necessary to treat serious complications, such as:³

• Life-threatening intestinal bleeding
• Bowel perforation (rupture)
• Toxic megacolon

In other cases, individuals choose to have surgery to remove the colon and rectum. They may choose surgery because their symptoms have become unbearable and medications are no longer working. They might choose surgery if the medication side effects are intolerable.⁷ Finally, some people with ulcerative colitis have surgery to prevent colorectal cancer

"Proctocolectomy" is the term that means surgical removal of the colon and rectum.⁷ A "stoma" is a hole in the abdomen that a surgeon creates for digestive waste to leave the body. When the stoma is connected to the end of the small intestine (ileum), it is called an "ileostomy."

There are two kinds of surgery for ulcerative colitis:^2,7

• Proctocolectomy with ileoanal reservoir (also called ileal pouch-anal anastomosis)
• Proctocolectomy with ileostomy

A proctocolectomy with ileoanal reservoir is the most common surgery for ulcerative colitis.⁷ In this procedure, the colon and rectum are removed. The anus and sphincter muscles are left intact. The surgeon creates a pouch at the end of the small intestine (the ileum). The pouch is connected to the anus. A temporary ileostomy may be needed while the pouch is healing. However, the benefit of this surgery is that the patient does not need a permanent ileostomy. Once the small intestine is attached to the anus, waste can pass out of the body through the anus.

In a total proctocolectomy with ileostomy, the colon, rectum and anus are removed.^2,7 The surgeon creates an ileostomy. An external pouch is attached to the stoma. The pouch collects stool that has passed through the digestive tract. This ileostomy is permanent.

Diet and nutrition

Diet does not cause ulcerative colitis.^2,3 However, if you have ulcerative colitis, you might find that making certain diet changes can improve your symptoms, especially during a flare. Ulcerative colitis is different for everyone. There is no single recommendation about which foods to eat or avoid. One way to connect particular foods with symptoms is to keep a food diary.