Treatments and drugs

By Mayo Clinic Staff

The goal of medical treatment is to reduce the inflammation that triggers your signs and symptoms. In the best cases, this may lead not only to symptom relief but also to long-term remission. Ulcerative colitis treatment usually involves either drug therapy or surgery.

Doctors use several categories of drugs that control inflammation in different ways. But drugs that work well for some people may not work for others, so it may take time to find a medication that helps you. In addition, because some drugs have serious side effects, you'll need to weigh the benefits and risks of any treatment.

Anti-inflammatory drugs

Anti-inflammatory drugs are often the first step in the treatment of inflammatory bowel disease. They include:

  • Sulfasalazine (Azulfidine). Sulfasalazine can be effective in reducing symptoms of ulcerative colitis, but it has a number of side effects, including nausea, vomiting, diarrhea, heartburn and headache. Don't take this medication if you're allergic to sulfa medications.
  • Mesalamine (Asacol, Lialda, others), balsalazide (Colazal) and olsalazine (Dipentum). These medications are available in oral forms and also in topical forms, such as enemas and suppositories. Which form you take depends on the area of your colon that's affected by ulcerative colitis. These medications tend to have fewer side effects than sulfasalazine and are generally very well tolerated. Your doctor may prescribe a combination of two different forms, such as an oral medication and an enema or suppository. Mesalamine can relieve signs and symptoms in more than 90 percent of people with mild ulcerative colitis. People with proctitis tend to respond better to combination therapy with oral mesalamine and suppositories. For left-sided colitis, a combination of oral mesalamine and mesalamine enemas seems to work better than either agent alone if symptoms are mild to moderate. Rare side effects include headache, kidney problems and pancreas problems (pancreatitis).
  • Corticosteroids. Corticosteroids can help reduce inflammation, but they have numerous side effects, including weight gain, excessive facial hair, mood swings, high blood pressure, type 2 diabetes, osteoporosis, bone fractures, cataracts, glaucoma and an increased susceptibility to infections. Doctors generally use corticosteroids only if you have moderate to severe inflammatory bowel disease that doesn't respond to other treatments. Corticosteroids aren't for long-term use, and the dose is usually tapered down over two to three months.

They may also be used in conjunction with other medications as a means to induce remission. For example, corticosteroids may be used with an immune system suppressor — the corticosteroids can induce remission, while the immune system suppressors can help maintain remission. Occasionally, your doctor may also prescribe short-term use of steroid enemas to treat disease in your lower colon or rectum.

Immune system suppressors

These drugs also reduce inflammation, but they target your immune system rather than treating inflammation itself. Because immune suppressors can be effective in treating ulcerative colitis, scientists theorize that damage to digestive tissues is caused by your body's immune response to an invading virus or bacterium or even to your own tissue. By suppressing this response, inflammation is also reduced. Immunosuppressant drugs include:

  • Azathioprine (Azasan, Imuran) and mercaptopurine (Purinethol). Because azathioprine and mercaptopurine act slowly — taking three months or longer to start working — they're sometimes initially combined with a corticosteroid, but in time, they seem to produce benefits on their own and the steroids can be tapered off.

    Side effects can include allergic reactions, bone marrow suppression, infections, and inflammation of the liver and pancreas. There also is a small risk of development of cancer with these medications. If you're taking either of these medications, you'll need to follow up closely with your doctor and have your blood checked regularly to look for side effects. If you've had cancer, discuss this with your doctor before starting these medications.

  • Cyclosporine (Gengraf, Neoral, Sandimmune). This potent drug is normally reserved for people who don't respond well to other medications or who face possible surgery because of severe ulcerative colitis. In some cases, cyclosporine may be used to delay surgery until you're strong enough to undergo the procedure. In others, it's used to control signs and symptoms until less toxic drugs start working. Cyclosporine begins working in one to two weeks, but because it has the potential for severe side effects, including kidney damage, seizures and fatal infections, talk to your doctor about the risks and benefits of treatment. There's also a small risk of cancer with these medications, so let your doctor know if you've previously had cancer.
  • Infliximab (Remicade). This drug is specifically for those with moderate to severe ulcerative colitis who don't respond to or can't tolerate other treatments. It works quickly to bring on remission, especially for people who haven't responded well to corticosteroids. This drug can sometimes prevent surgery for some people. It works by neutralizing a protein produced by your immune system known as tumor necrosis factor (TNF). Infliximab finds TNF in your bloodstream and removes it before it causes inflammation in your intestinal tract.

    Some people with heart failure, people with multiple sclerosis, and people with cancer or a history of cancer can't take infliximab. The drug has been linked to an increased risk of infection, especially tuberculosis and reactivation of viral hepatitis, and may increase your risk of blood problems and cancer. You'll need to have a skin test for tuberculosis, a chest X-ray and a test for hepatitis B before taking infliximab.

    Also, because infliximab contains mouse protein, it can cause serious allergic reactions in some people — reactions that may be delayed for days to weeks after starting treatment. Once started, infliximab is generally continued as long-term therapy, although its effectiveness may decrease over time.

  • Adalimumab (Humira) is an alternative to inflixmab for people whose ulcerative colitis has not been helped by other medications such as azathioprine or 6 mercaptopurine. It may also be considered for people who initially improve with infliximab but then improvement stops; but its benefit in this situation remains unproven. Adalimumab, like infliximab, carries a small risk of infections, including tuberculosis and serious fungal infections. Before taking adalimumab, you should have a skin test for tuberculosis, a chest X-ray and a test for hepatitis B. The most common side effects of adalimumab are skin irritation and pain at the injection site, nausea, runny nose and upper respiratory infection.

Other medications

In addition to controlling inflammation, some medications may help relieve your signs and symptoms. Depending on the severity of your ulcerative colitis, your doctor may recommend one or more of the following:

  • Antibiotics. People with ulcerative colitis who run fevers will likely be given antibiotics to help prevent or control infection.
  • Anti-diarrheals. For severe diarrhea, loperamide (Imodium) may be effective. Use anti-diarrheal medications with great caution, however, because they increase the risk of toxic megacolon.
  • Pain relievers. For mild pain, your doctor may recommend acetaminophen (Tylenol, others). Don't use ibuprofen (Advil, Motrin, others), naproxen (Aleve) or aspirin. These are likely to make your symptoms worse.
  • Iron supplements. If you have chronic intestinal bleeding, you may develop iron deficiency anemia. Taking iron supplements may help restore your iron levels to normal and reduce this type of anemia once your bleeding has stopped or diminished.

Surgery

If diet and lifestyle changes, drug therapy, or other treatments don't relieve your signs and symptoms, your doctor may recommend surgery.

Surgery can often eliminate ulcerative colitis. But that usually means removing your entire colon and rectum (proctocolectomy). In the past, after this surgery you would wear a small bag over an opening in your abdomen (ileal stoma) to collect stool. But a procedure called ileoanal anastomosis eliminates the need to wear a bag. Instead, your surgeon constructs a pouch from the end of your small intestine. The pouch is then attached directly to your anus. This allows you to expel waste more normally, although you may have more-frequent bowel movements that are soft or watery because you no longer have your colon to absorb water.

Pregnancy

Women with ulcerative colitis can usually have successful pregnancies, especially if they can keep the disease in remission during pregnancy. Ideally, you'll become pregnant when your disease is in remission. Some medications may not be indicated for use in pregnancy, especially during the first trimester, and the effects of certain medications may linger after you stop them. Talk with your doctor about the best way to manage your illness before you conceive. If you stop certain medications, their effects may linger. It's estimated that the risk of passing ulcerative colitis to your unborn child if your partner doesn't have ulcerative colitis is less than 10 percent.

Cancer surveillance

Screening for colon cancer often needs to be done more frequently because people who have ulcerative colitis have an increased risk of colon cancer. It's recommended that people with pancolitis begin colon cancer screening with a colonoscopy eight years after diagnosis. For those who have left-sided colitis, screening with colonoscopy is recommended beginning 10 years after diagnosis. People with proctitis can follow the usual colon cancer screening guidelines that call for a colonoscopy every 10 years beginning at age 50.

Oct. 10, 2012