What is the treatment for ulcerative colitis?

Treatment for Ulcerative Colitis

The first-line treatment for ulcerative colitis is 5-aminosalicylic acid (5-ASA) compounds, with escalation to corticosteroids for non-responders and advanced therapies (biologics or small molecules) for refractory disease. 1

Treatment Algorithm Based on Disease Severity

Mild to Moderate Disease

1. First-line therapy:

   • Distal UC: Combination of topical mesalazine 1g daily plus oral mesalazine 2-4g daily 1
   • Extensive UC: Oral mesalazine 2-4g daily or balsalazide 6.75g daily 1
   • Once-daily dosing is as effective as divided doses for maintenance therapy, which may improve compliance 2

2. If no response within 2-4 weeks:

   • Add oral prednisolone 40mg daily 1
   • Note: Corticosteroids should never be used for long-term maintenance due to side effects 1

Moderate to Severe Disease

1. Induction therapy:

   • IV methylprednisolone 60 mg/day or hydrocortisone 100 mg four times daily 1
   • Consider early biological therapy initiation in appropriate patients 1

2. For refractory disease:

   • Infliximab 5 mg/kg IV at weeks 0,2, and 6, followed by maintenance every 8 weeks 3
   • Other advanced therapies: anti-integrin agents, IL-12/23 inhibitors, JAK inhibitors, or S1P receptor modulators 1

Maintenance Therapy

• All patients should receive maintenance therapy with 5-ASA compounds at ≥2g/day for lifelong use 1
• For frequent relapsers (more than once per year): Consider azathioprine 1.5-2.5mg/kg/day or mercaptopurine 0.75-1.5mg/kg/day 1
• Important safety note: Cases of hepatosplenic T-cell lymphoma have been reported in patients treated with TNF blockers (like infliximab) combined with azathioprine or 6-mercaptopurine, particularly in young males with Crohn's disease or ulcerative colitis 3

Risk Factors for 5-ASA Treatment Failure

Patients with the following characteristics may need earlier escalation to advanced therapies 4:

• Younger age at diagnosis
• Extensive colitis
• Endoscopic activity at diagnosis
• Early need for corticosteroids
• Elevated inflammatory markers
• Medication non-adherence

Monitoring and Treatment Goals

• Treatment goals have evolved from clinical response to achieving biochemical, endoscopic, and histological remission 1
• Monitor symptoms and biomarkers of inflammation (e.g., fecal calprotectin) 5
• Colonoscopy surveillance for dysplasia should begin 8 years after diagnosis 5

Supportive Care

• Ensure adequate fluid intake
• Avoid foods that worsen symptoms
• Consider small, frequent meals rather than large meals
• Stay current with vaccinations, especially if on immunosuppressive therapy
• Moderate exercise when symptoms are controlled; rest during flares
• Keep a symptom diary to track symptoms and identify triggers 1
• Smoking cessation is crucial for maintaining remission 1

Important Considerations for Advanced Therapies

• Before starting biologics like infliximab (RENFLEXIS), screen for latent tuberculosis and other infections 3
• Anti-TNF agents are more effective when combined with immunomodulators than as monotherapy, but this combination increases risk of certain complications 1
• Patients on biologics require regular monitoring for infections and other adverse effects 3

Despite advances in medical therapies, approximately 20% of patients with UC are hospitalized within 5 years of diagnosis, and about 7% require colectomy 5. Early identification of patients who may fail conventional therapy and appropriate therapeutic escalation are essential to prevent disease progression and improve outcomes.