Ulcerative colitis (UC), a chronic inflammatory bowel disease, continues to be the subject of extensive scientific research as medical professionals seek better ways to manage this challenging condition. Recent developments include FDA approval of new medications, with researchers actively studying additional treatments in clinical trials.
The primary goal of UC treatment is to stop the immune system from attacking the intestinal lining, thereby reducing inflammation, alleviating symptoms, and achieving remission. Doctors now have an expanding arsenal of medications to help patients reach these objectives.
Treatment selection depends on several factors: disease severity (mild, moderate, or severe), previously tried medications, response to those treatments, and overall health status.
Aminosalicylates represent the first-line treatment for UC, containing the active ingredient 5-aminosalicylic acid (5-ASA). This category includes mesalamine (Apriso, Asacol HD, Canasa, Pentasa), olsalazine (Dipentum), balsalazide (Colazal), and sulfasalazine (Azulfidine).
These medications, taken orally or as enemas, reduce intestinal inflammation and work best for mild to moderate UC. They have demonstrated effectiveness in both inducing and maintaining remission.
The American Gastroenterological Association (AGA) strongly recommends that adults with mild to moderate UC choose a standard dose of oral mesalamine, olsalazine, or balsalazide over low-dose mesalamine, sulfasalazine, or no treatment. A standard mesalamine dose is 2 to 3 grams daily.
Recent research examining UC prevalence in the Middle East called 5-ASA "the gold standard for the induction of remission in patients with mild to moderate UC according to multiple international guidelines," reinforcing the AGA's recommendation.
Corticosteroids suppress the immune system to reduce inflammation and are typically used for patients hospitalized with acute severe UC. Examples include prednisone (Prednisone Intensol, Rayos), prednisolone (Prelone, Millipred), methylprednisolone (Medrol), and budesonide (Uceris).
Doctors may also prescribe these medications short-term to manage symptom flares. Administration methods include oral tablets, injections, intravenous infusion, and rectal foam.
However, long-term steroid use isn't advisable due to potential side effects including high blood sugar, weight gain, infections, and bone loss. Patients should discuss these risks and treatment timelines with their healthcare providers.
Immunomodulators suppress the immune system to prevent inflammation and are typically combined with biologics to treat severe UC. Doctors may prescribe these medications when symptoms don't respond to aminosalicylates.
Examples include azathioprine (Azasan, Imuran), mercaptopurine (Purixan), and methotrexate (Otrexup, Trexall, Rasuvo). Methotrexate can increase the risk of stomach and intestinal problems, and a 2018 study suggested it may not effectively help people with UC maintain remission.
In 2020, an AGA expert panel recommended using immunomodulators in combination with biologics for moderate to severe UC when aminosalicylates haven't worked. While the FDA hasn't approved immunomodulators specifically for UC treatment, doctors may still prescribe them off-label.
Biologics are manufactured from genetically engineered proteins or other natural substances that target specific immune system components driving inflammation.
A 2023 research review examined five licensed biologics:
Adalimumab: Effective in both short and long-term treatment Infliximab: Induces short-term response, remission, and mucosal healing Golimumab: Similar to other biologics but requires more dose monitoring Vedolizumab: Shows higher remission rates than adalimumab and costs less Ustekinumab: The newest drug improves remission rates but requires more research
Anti-TNF drugs block tumor necrosis factor (TNF), an immune system protein that triggers inflammation. These medications help people with moderate to severe UC whose symptoms haven't improved with other treatments.
TNF blockers include adalimumab (Humira), golimumab (Simponi), and infliximab (Remicade). Adalimumab and golimumab are administered via subcutaneous injection, while infliximab is given through IV infusion.
Vedolizumab treats moderate to severe disease by preventing damaging white blood cells from entering the gastrointestinal tract and causing inflammation. Previously available only through IV infusion, the FDA recently approved subcutaneous administration.
The AGA suggests that people with moderate to severe UC who are new to biologics choose infliximab or vedolizumab rather than adalimumab, as the former options are more effective.
However, some patients may find adalimumab more convenient since it can be self-administered, while other biologics require healthcare professional administration. Adalimumab is a reasonable choice if you prefer self-injectable medication or find it more accessible or affordable. Patients should discuss all options with their doctors.
When medications fail to control symptoms or complications arise, surgery may become necessary. This typically involves removing the affected portion of the colon.
The Takeaway
Beyond currently available medications, researchers continue investigating new and potentially improved treatments through clinical trials. In 2023, the FDA approved a new medication for treating moderate to severe UC in adults, expanding the therapeutic options available to patients.
The landscape of UC treatment continues to evolve, with an increasing number of effective medications and ongoing research promising additional options. Working closely with healthcare providers to find the right treatment combination—considering disease severity, previous treatments, and individual circumstances—remains key to successfully managing ulcerative colitis and achieving lasting remission.
