What are the treatment options for ulcerative colitis (UC)?

From the Guidelines

Treatment for colitis should initially involve a combination of an aminosalicylate enema and oral mesalamine, with corticosteroids reserved for moderate to severe cases or those who do not respond to initial therapy. This approach is based on the most recent and highest quality evidence available, including the 2023 study on ozanimod for the treatment of ulcerative colitis 1.

Key Considerations

• For mild to moderately active extensive ulcerative colitis, an aminosalicylate enema 1 g/day combined with oral mesalamine ≥ 2.4 g/day is recommended as first-line treatment 1.
• Corticosteroids, such as prednisone, may be prescribed for moderate to severe flares but are not recommended for long-term use due to side effects 1.
• Immunosuppressants like azathioprine or biologics such as infliximab may be necessary for more severe cases or when other treatments fail 1.
• Dietary modifications, including avoiding trigger foods and increasing fiber gradually during remission, are important supportive measures.
• Probiotics may help some patients maintain remission, although the evidence is not yet conclusive 1.

Recent Developments

• The emergence of biologic agents and small molecule therapies, such as ozanimod, has revolutionized the treatment of moderately to severely active ulcerative colitis, offering advantages such as oral administration and reduced risk of immunogenicity 1.
• However, these treatments also come with potential risks and side effects, emphasizing the need for careful patient selection and monitoring.

Treatment Goals

• The primary goal of treatment is to achieve complete remission, defined as both symptomatic and endoscopic remission without corticosteroid therapy 1.
• Treatment should aim to reduce inflammation, modulate the immune response, and allow the intestinal tissue to heal, thereby relieving symptoms like diarrhea, abdominal pain, and rectal bleeding.

From the FDA Drug Label

1. 3 Ulcerative Colitis RENFLEXIS is indicated for reducing signs and symptoms, inducing and maintaining clinical remission and mucosal healing, and eliminating corticosteroid use in adult patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy.
2. 4 Pediatric Ulcerative Colitis RENFLEXIS is indicated for reducing signs and symptoms and inducing and maintaining clinical remission in pediatric patients 6 years of age and older with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy.

Treatment for Colitis: Infliximab (IV) is indicated for reducing signs and symptoms, inducing and maintaining clinical remission, and mucosal healing in patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy 2.

• The recommended dose of infliximab for adult patients with moderately to severely active ulcerative colitis is 5 mg/kg given as an intravenous induction regimen at 0,2, and 6 weeks, followed by a maintenance regimen of 5 mg/kg every 8 weeks 2.
• For pediatric patients 6 years and older with moderately to severely active ulcerative colitis, the recommended dose is 5 mg/kg given as an intravenous induction regimen at 0,2, and 6 weeks, followed by a maintenance regimen of 5 mg/kg every 8 weeks 2.

From the Research

Treatment Options for Colitis

• The primary goal of treatment is to induce and maintain clinical remission, as well as screen for complications of the disease 3.
• Mesalamine, a 5-aminosalicylic acid compound, is the first-line therapy for inducing and maintaining clinical remission in patients with mild-to-moderate ulcerative colitis (UC) 3, 4, 5, 6.
• For patients who are refractory to mesalamine or have more severe disease, other treatment options include steroids, azathioprine/mercaptopurine, cyclosporine, or infliximab 3, 4, 6.

Treatment Approaches

• Topical treatment with 5-aminosalicylic acid (5-ASA) is the treatment of choice for active distal mild-to-moderate UC 4.
• Oral aminosalicylates are effective in both distal and extensive mild-to-moderate disease, but may have lower rates of remission in distal disease compared to topical 5-ASA 4.
• New steroids, such as budesonide and beclomethasone dipropionate (BDP), administered as enemas, may be an alternative to 5-ASA therapy 4.
• Patients with severe disease may require oral corticosteroids, intravenous therapy, or immunosuppressive therapy with cyclosporine 4, 6.

Maintenance of Remission

• Oral aminosalicylates are the first-line therapy for maintaining remission in UC 4, 6.
• Topical 5-ASA may play a role in maintaining remission in distal disease 4.
• Azathioprine or 6-mercaptopurine may be used to maintain remission in patients who are steroid-dependent 4.
• Biologic therapy with infliximab may be used in patients with more severe disease, although its use has not been established in all cases 4, 7.