Ulcerative Colitis Cannot Heal Without Medication
No, a patient with ulcerative colitis cannot reliably heal without medication, and attempting to do so significantly increases the risk of disease complications, hospitalization, colectomy, and reduced life expectancy. 1, 2
Why Medication is Essential
UC is a chronic inflammatory disease requiring lifelong medical management to achieve and maintain remission, prevent complications, and preserve quality of life. 1, 3, 2
Untreated UC leads to serious outcomes: Within 5 years of diagnosis, approximately 20% of patients require hospitalization and 7% undergo colectomy. 2
Life expectancy is reduced by approximately 5 years in patients with UC compared to the general population (80.5 years for females, 76.7 years for males), and this gap would be substantially worse without treatment. 2
Colorectal cancer risk increases significantly: After 20 years of disease duration, the risk of colorectal cancer is 4.5%, representing a 1.7-fold higher risk compared to people without UC. 2
Evidence-Based Treatment Requirements
For Mild to Moderate Disease
First-line therapy with 5-aminosalicylic acid (5-ASA) is mandatory for both induction and maintenance of remission in mild to moderate UC. 1, 2
Topical mesalazine 1 g daily combined with oral mesalazine 2-4 g daily represents the most effective first-line approach for distal colitis. 1
Combination therapy (oral plus topical 5-ASA) is superior to either agent alone and should be the standard approach. 1
For Moderate to Severe Disease
Advanced therapies are required when 5-ASA fails, including biologics (infliximab, vedolizumab, adalimumab, golimumab, ustekinumab) or small molecules (tofacitinib, upadacitinib, ozanimod). 1
Infliximab or vedolizumab are preferred as first-line biologics over adalimumab due to superior efficacy in inducing remission in biologic-naïve patients. 1, 4
Combination therapy with biologics plus immunomodulators (thiopurines or methotrexate) is more effective than monotherapy for achieving corticosteroid-free remission. 1, 4
For Severe/Acute Disease
Hospitalization with intravenous corticosteroids is required for acute severe UC (methylprednisolone 30 mg every 12 hours or hydrocortisone 100 mg 6-hourly). 1
Rescue therapy with infliximab or ciclosporin is necessary if no response occurs within 3 days of IV corticosteroids. 1
Emergency colectomy may be life-saving for patients with toxic megacolon, perforation, severe hemorrhage, or failure of medical rescue therapy within 7 days. 1, 3
Consequences of Avoiding Medication
Disease progression is inevitable without treatment, leading to more extensive colonic involvement, increased inflammation, and higher risk of complications. 3, 5
Quality of life deteriorates significantly due to chronic bloody diarrhea, abdominal pain, fecal urgency, and tenesmus. 3, 2
Extraintestinal manifestations occur in approximately 27% of patients, including primary sclerosing cholangitis, arthritis, and skin manifestations, which also require medical management. 2
Nutritional deficiencies and anemia develop from chronic inflammation and blood loss. 1, 3
Critical Pitfalls to Avoid
Never delay appropriate medical therapy in hopes of spontaneous remission, as this increases morbidity and mortality. 4, 5
Do not use corticosteroids for maintenance therapy, as they are ineffective for this purpose and cause significant adverse effects with prolonged use. 1
Avoid repeated courses of corticosteroids without escalating to appropriate maintenance therapy (biologics or immunomodulators). 1
Do not attempt thiopurine monotherapy for active disease induction, as it is ineffective and delays appropriate treatment. 1
Monitoring Requirements Even With Treatment
Regular colonoscopy surveillance is mandatory starting at 8 years from diagnosis to screen for dysplasia and colorectal cancer. 2
Biomarkers of inflammation (fecal calprotectin, C-reactive protein) require ongoing monitoring to assess disease activity. 1, 2
Clinical assessment every 2 weeks during induction therapy is necessary to determine treatment response and need for escalation. 1