Ulcerative Colitis Treatments and Medications

Unfortunately, when the colon starts having problems, life can get pretty challenging. People with ulcerative colitis, a chronic condition that causes inflammation in the colon, know exactly how challenging colon problems can be. Fortunately, there are some treatments to help with ulcerative colitis. They aren’t cures, but they can keep the symptoms at bay and help restore normal life.

What is ulcerative colitis?

Ulcerative colitis is a lifelong disorder that causes inflammation and sores in the colon and rectum. For the million people in the United States living with ulcerative colitis, the illness goes through active flare-ups followed by periods of remission. The condition cannot be cured, so ulcerative colitis is treated by drugs that either prevent flare-ups or induce remission during a flare-up.

Along with Crohn’s disease, ulcerative colitis is part of a spectrum of disorders called inflammatory bowel disease (IBD). Both involve inflammation of gastrointestinal tissues caused by the immune system. Unlike Crohn’s disease, which can affect all the tissues in the gastrointestinal system, ulcerative colitis is limited to the lining (mucosa) of the rectum and colon.

Ulcerative colitis is divided into four types depending on the extent to which the colon is affected. In some patients, swelling is limited to just the rectum (ulcerative proctitis) or both to the rectum and the lower end of the colon called the sigmoid colon (proctosigmoiditis). Left-sided colitis extends from the rectum to the entire left side of the colon, or the descending colon. Pancolitis is marked by inflammation throughout the entire colon.

In general, the more of the colon that is affected, the more severe the symptoms. Fortunately, most cases are mild to moderate in both extent and the severity of symptoms during flare-ups. However, flare-ups in the most severe cases can be debilitating and even lethal. Ulcerative colitis raises the risk of colorectal cancer, but people with ulcerative colitis statistically live as long as the rest of the population.

No-one knows what causes ulcerative colitis. Genetics play a large role, but other factors, generally referred to as ‘environmental factors’, are believed to play a role as well. These factors might include gut infections (Salmonella or Campylobacter) or an imbalance in the colon’s bacteria. One theory is that flare-ups happen when the immune system overreacts to harmless bacteria in the gut. In the process, the immune system mistakenly attacks the lining of the colon and rectum, as well.

How is ulcerative colitis diagnosed?

The diagnosis of ulcerative colitis is made from the clinical symptoms, an endoscopic examination of the rectum and colon, and a biopsy of colon tissues. A stool test will be used to rule out infection. Lab testing may be done to corroborate the diagnosis and check for anemia. Diagnosis may begin with a general practitioner, but endoscopic examination and treatment of the condition usually fall to a gastroenterologist, a doctor who specializes in digestive diseases.

People usually seek medical help first during an active flare-up, showing symptoms of ulcerative colitis such as:

• Bloody diarrhea

• Abdominal pain and cramping

• Rectal bleeding

• Urgency to defecate

• Inability to defecate even when the need is urgent (tenesmus)

Severe disease will also include symptoms such as involuntary weight loss, fatigue, anemia, and fever. A small number of patients will have other symptoms not involving the gut. These include swollen or painful eye tissues, joint pain or swelling, and red lumps or sores/rashes on the skin.

In taking a history, a doctor will be interested in how quickly symptoms appeared, how often they’ve been experienced, the length of remissions, and risk factors such as age and family history of inflammatory bowel disease.

A definitive diagnosis is made with an endoscopic examination of the rectum and the colon (called a colonoscopy). The gastroenterologist is not only looking for signs of ulcerative colitis but also needs to determine how much of the colon is affected. Biopsies with multiple colon tissue samples will help to confirm the diagnosis.

X-rays, or other imaging will usually not be necessary unless the doctor suspects other problems or complications such as perforation.

Ulcerative colitis treatment options

Treatment of ulcerative colitis focuses on one of two goals: inducing remission during an active flare-up or maintaining remission. These goals are largely accomplished through medications that will be tailored to the severity and extent of the illness. Severe disease or complications may require surgical removal of part or all of the colon.

Medications

Medications are the first-line treatment for controlling active ulcerative colitis and maintaining remission. As a general rule, the same medications used to induce remission will also be used to maintain remission, but they will be taken at a lower dose. First-line ulcerative colitis medications work by blocking the body’s ability to produce inflammatory substances. If these don’t work, immune-suppressing or immune-altering medicines—thiopurines or biologics—will be used.

Surgery

Severe cases that do not respond to medical therapy will require surgical removal of part or all of the colon. The vast majority of the time, the entire colon is removed, since any part of the colon that is left in place can also become inflamed and be a risk for cancer. Complications such as colon cancer, uncontrollable bleeding, perforation, or massive swelling of the colon (toxic megacolon) are indications to send a patient for surgery.

Most patients will have the entire colon and rectum removed, with the last part of the small intestine (called the ileum), attached directly to the anus. In this way, the anus and anal sphincter, will be preserved. This procedure is called a total proctocolectomy with ileal pouch-anal anastomosis. This surgery can either be completed in one setting, or in 2 or even 3 ‘stages’.

Most of the time, the surgery will be completed in 2 stages, although this is determined by the individual surgeon and patient characteristics. In a 2 stage surgery, the entire colon and rectum are removed, a ‘J-pouch' is created and attached to the anus (this involves creating a small pouch at the end of the small intestine in the shape of a ‘J’), and the other end of the ileum is brought out to the abdominal wall, creating an ileostomy (a hole in the abdomen). After a few months of passing waste through the ileostomy , patients will then undergo a second surgery, during which the ileostomy will be ‘reversed’, and attached to the ileal pouch-anal anastomosis that was created during the first surgery After this is completed, the patient can then expel waste through the anus. Because ulcerative colitis only affects the colon and rectum, a proctocolectomy will technically cure the condition.

Complementary treatments

Probiotics, such as those containing Lactobacillus and Escherichia coli, have been shown in some studies to be effective at maintaining remission in ulcerative colitis. However, they do not help reduce symptoms or induce remission during an active flare-up. Acupuncture and wheatgrass can provide symptom relief during a flare-up, but they probably will not help induce remission. Green tea may also help ease symptoms. Hypnotherapy can be used to prevent flare-ups.

Ulcerative colitis medications

Medications are the foundation of ulcerative colitis treatment. They are used to induce remission and reduce symptoms in active ulcerative colitis. During remission phases, the same drugs will be continued but may be given at lower doses to prevent flare-ups.

Aminosalicylates

The first-line treatment for ulcerative colitis involves aminosalicylates, either mesalamine (also called 5-aminosalicylic acid or ASA) or sulfasalazine. Aminosalicylates block the production of inflammatory substances. They can be taken both orally and via a suppository or enema. The suppositories and enemas are more effective for disease limited to the rectum and sigmoid colon. They will be taken both in the active and remission phase of ulcerative colitis.

Corticosteroids

If aminosalicylates do not work, a gastroenterologist may prescribe corticosteroids. Steroids come in suppositories, rectal foams, enemas, or pills and rapidly reduce swelling in the colon. Severe flare-ups that require hospitalization will require a cortisone injection intravenously. Because of side effects, steroids should never be used to maintain remission.

Immunosuppressants (immunomodulators)

If corticosteroids and aminosalicylates do not induce remission, the gastroenterologist will turn to medications that suppress or modulate the immune system. For ulcerative colitis, the drugs of choice are thiopurines: azathioprine or mercaptopurine. If these drugs don’t work, more powerful immune suppressants, cyclosporine or methotrexate, may be used. Thiopurines are used to maintain remission but at a lower dose. It should be noted that the thiopurines take a few months to reach an appropriate level in the bloodstream.

Biologics

For active flare-ups of moderate to severe ulcerative colitis, synthetic antibodies called “biologics” are used to intervene in one of the steps of the abnormal immune system response and reduce intestinal swelling. Drugs like Remicade (infliximab), Humira (adalimumab), Simponi (golimumab), Stelara (ustekinumab), and Entyvio (vedolizumab) glue themselves to proteins the body uses to “signal” the immune system, essentially shutting the whole process down. Because of the risk of infection or cancer, biologics are not recommended to maintain remission after a flare-up has passed.

What is the best medication for ulcerative colitis?

The severity and extent of ulcerative colitis will determine the most appropriate medications for the condition. For this reason, there is no “best” medication for ulcerative colitis. Instead, a patient’s medical situation and tolerance for side effects will determine the best medications for treating ulcerative colitis.

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