Treatment for Ulcerative Colitis

Introduction to Treatment

• The European Crohn’s and Colitis Organisation recommends that treatment for colitis should be tailored based on disease extent, severity, and type, with aminosalicylates (5-ASA) as first-line therapy for mild to moderate ulcerative colitis, combined with topical therapy for distal disease, and systemic corticosteroids for more severe disease or those who fail to respond to 5-ASA therapy 1, 2, 3

Treatment Based on Disease Extent and Severity

• For mild to moderate distal UC, the American Gastroenterological Association suggests that topical mesalazine 1g daily combined with oral mesalazine ≥2.4g daily is the most effective first-line therapy 1, 2
• The European Crohn’s and Colitis Organisation recommends that topical mesalazine is more effective than topical corticosteroids and should be the preferred topical agent 2, 4
• Once-daily dosing with mesalazine is as effective as divided doses, according to the Journal of Crohn's and Colitis 1
• The American Gastroenterological Association suggests that topical formulation should be selected based on disease extent: suppositories for disease limited to rectum, foam or liquid enemas for more proximal disease 2, 4
• Patients who fail to improve on combination therapy should be treated with oral prednisolone 40mg daily, as recommended by the European Crohn’s and Colitis Organisation 2, 3
• Mild to moderate extensive UC should be treated with oral mesalazine ≥2.4g daily combined with topical mesalazine enemas 1g daily, according to the American Gastroenterological Association 1, 3
• Systemic corticosteroids (prednisolone 40mg daily) are appropriate for moderate to severe disease or for patients with mild disease who don't respond to mesalazine, as recommended by the European Crohn’s and Colitis Organisation 1, 3
• Prednisolone should be tapered gradually over approximately 8 weeks according to patient response, according to the Journal of Crohn's and Colitis 3, 5
• Severe extensive colitis requires hospital admission for intensive treatment, as recommended by the American Gastroenterological Association 1
• Severe ulcerative colitis requires hospital admission and joint management by gastroenterologist and colorectal surgeon, according to the European Crohn’s and Colitis Organisation 2, 6

Medication Options

• The American Gastroenterological Association recommends that aminosalicylates (5-ASA) are first-line therapy for mild to moderate UC 2, 3
• Options include mesalazine (2-4g daily), balsalazide (6.75g daily), olsalazine (1.5-3g daily), as suggested by the European Crohn’s and Colitis Organisation 3, 5
• Combination of oral and topical 5-ASA is more effective than either alone, according to the Journal of Crohn's and Colitis 2
• Sulfasalazine (2-4g daily) has higher incidence of side effects compared to newer 5-ASA drugs, as reported by the American Gastroenterological Association 2, 3
• Corticosteroids are indicated for moderate to severe UC or when 5-ASA therapy fails, according to the European Crohn’s and Colitis Organisation 1, 7
• Oral prednisolone 40mg daily is standard dosing, as recommended by the American Gastroenterological Association 2, 3
• Azathioprine (1.5-2.5mg/kg/day) or mercaptopurine (0.75-1.5mg/kg/day) are indicated for steroid-dependent disease, according to the European Crohn’s and Colitis Organisation 3, 5
• Probiotics (particularly VSL#3) may be used as adjunctive therapy, as suggested by the Journal of Crohn's and Colitis 1, 8

Maintenance Therapy

• Lifelong maintenance therapy is generally recommended, especially for left-sided or extensive disease, according to the European Crohn’s and Colitis Organisation 6
• 5-ASA compounds are effective and safe for maintenance therapy, as reported by the American Gastroenterological Association 6
• Immunomodulators can be used for maintenance in steroid-dependent patients, according to the European Crohn’s and Colitis Organisation 3

Special Considerations

• Proximal constipation should be treated with stool bulking agents or laxatives, as recommended by the American Gastroenterological Association 2
• Fecal transplantation shows promise but requires further research to define optimal protocols, according to the Journal of Crohn's and Colitis 1
• Treatment should aim for complete remission, assessed biochemically, endoscopically, and histologically, as recommended by the European Crohn’s and Colitis Organisation 7