When to Stop Treatment in Ulcerative Colitis
Maintenance therapy for ulcerative colitis (UC) should be lifelong for most patients, especially those with left-sided or extensive disease, though discontinuation may be considered for patients with distal disease who have been in remission for at least 2 years and are averse to medication. 1
General Principles for Maintenance Therapy
- Lifelong maintenance therapy is generally recommended for all patients with UC, particularly those with left-sided or extensive disease 1
- Patients with distal disease who relapse more than once a year should remain on maintenance therapy indefinitely 1
- Maintenance therapy should be continued with the agent successful in achieving induction, with the important exception that corticosteroids are not recommended for long-term maintenance 1
When Discontinuation May Be Considered
Patients with Distal Disease
- Discontinuation of medication may be reasonable for patients with distal disease (proctitis) who have been in stable remission for at least 2 years 1
- These patients should be informed that they are still at risk of relapse, though the risk is lower after prolonged remission 2
- A study showed that patients in remission for over 2 years had no significant difference in relapse rates between mesalazine and placebo groups after 12 months (18% vs 26%) 2
Factors to Consider Before Stopping Therapy
- Duration of remission (longer remission periods are associated with lower relapse rates) 2
- Disease extent (distal disease has better prognosis than extensive disease) 1
- Previous disease severity and frequency of relapses 1
- Patient preference regarding medication continuation 1
- Presence of risk factors for colorectal cancer (maintenance therapy may reduce this risk) 1
Medication-Specific Considerations
5-ASA Medications
- For patients in remission on 5-ASA, continuation is generally recommended at a dose of at least 2 g/day 1
- 5-ASAs can be discontinued in patients who have failed these agents and escalated to immunomodulators or advanced therapies 1
- Exception: Patients with residual proctitis may benefit from continuing rectal 5-ASA even when on advanced therapies 1
Corticosteroids
- Corticosteroids should never be used for maintenance therapy 1
- Prednisolone should be reduced gradually according to severity and patient response, generally over 8 weeks 1
Immunomodulators and Biologics
- For patients in remission on TNF antagonists plus immunomodulators for at least 6 months, withdrawal of the TNF antagonist is not recommended 1
- There is insufficient evidence to make a recommendation about withdrawing immunomodulators while continuing TNF antagonists in patients on combination therapy 1
Special Situations
Severe Acute Ulcerative Colitis
- In severe UC not responding to maximal medical therapy after 4-7 days, treatment should be stopped and the patient should undergo colectomy 3
- Prolonged observation in severe UC is counterproductive and increases risk of toxic megacolon and perforation 3
- Colectomy should not be seen as a last resort but as a potentially life-saving procedure 3
Failed Medical Therapy
- Treatment should be stopped and surgical options considered when:
Monitoring After Treatment Discontinuation
- Regular follow-up visits to assess for symptom recurrence 4
- Monitoring of inflammatory markers such as fecal calprotectin 4
- Patient education about recognizing early signs of relapse 1
- Prompt reinitiation of therapy if symptoms recur 1
Pitfalls to Avoid
- Continuing corticosteroids for long-term maintenance (associated with significant adverse effects) 1
- Stopping therapy prematurely in patients with extensive disease or frequent relapses 1
- Delaying surgical intervention in severe UC not responding to medical therapy 3
- Continuing 5-ASAs in patients who have failed these agents and escalated to advanced therapies (unless they have residual proctitis) 1