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Ulcerative Colitis

Treatment Of Ulcerative Colitis

Last modified: 
26/04/2012 - 09:32

Contributing Author: Guy Slowik FRCS

Medical management of ulcerative colitis begins with an attempt to reduce the symptoms and bring on a remission. After this is accomplished, the goal is to maintain remission for as long as possible.

Treatment options include:

Medications

Most of the medications used to treat ulcerative colitis are generally safe for long-term use, and many individuals stay on maintenance doses of medications indefinitely. Medications include:

  • 5-ASA Compounds - A number of medications used to treat ulcerative colitis all have as their active ingredient 5-aminosalicylic acid (5-ASA). These include sulfasalazine (trade nameAzulfadine), a compound that has been used for more than half a century. The sulfapyradine in sulfasalazine causes a number of side effects, which include mild to severe headaches, nausea, and vomiting. These are usually dose-related, although some people cannot tolerate the medication at all. Azulfadine can be purchased in an enteric-coated tablet, which helps many people reduce the nausea caused by uncoated tablets.

    For years, scientists sought ways to deliver 5-ASA without the sulfa-drug side effects. During the 1990s, a number of new 5-ASA medications were approved. None are yet available as generics. They can be found under the following trade names and in the following formulations:

    • Asacol (mesalamine), available as a 400-milligram coated caplet
    • Pentasa (mesalamine), available as a 250-milligram capsule
    • Rowasa (mesalamine), available as a 500-milligram rectal suppository or a 4,000-milligram enema, and which has been shown to be especially effective in proctitis, proctosigmoiditis, and left-sided colitis
    • Dipentum (osalazine), available as a 250-milligram capsule

    Evidence shows that all the new 5-ASA compounds are effective in large doses for treatment of flare-ups, and in lower doses for maintenance therapy. In general, the particular compound and method of administration (oral or rectal) used to bring about remission of a flare-up is the same compound and method that should be used for maintenance.

    Because these medications are all expensive, many doctors continue to use sulfasalazine as the first medical treatment.

  • Steroids - Steroids are powerful drugs that reduce inflammation and suppress the body's immune system. Steroids can be applied topically by enema (easily placed directly into the rectum) for treatment of proctitis, proctosigmoiditis, and left-sided colitis, or taken by mouth for pancolitis or for any disease that does not respond to topical steroids.

    Steroids are used to treat moderate-to-severe symptoms during a flare-up. Steroids have not been shown to be beneficial as a maintenance therapy, and individuals should be weaned off steroids as quickly as possible.

    Prednisone and prednisolone are the most commonly used steroids for ulcerative colitis treatment. While they are very useful, they also can produce a number of side effects, which range from annoying to dangerous. Some side effects are more often seen with long-term use, while others can appear from even short-term use.

    • Long-term side effects include "mooning" of the face, acne, insomnia, tremors, night sweats, and significant weight gain. Mood disturbances and some sleep disturbances can occur with even short-term use.
    • Dangerous side effects include increased blood pressure, osteoporosis, severe depression, and occasionally even psychosis (a confused state of not knowing what is real and what is not). Long-term steroid use can also cause cataracts and glaucoma.

    Nice To Know:

    Q. Should I be worried about steroid treatment?

    A. Steroids have proved to be powerfully effective medications for literally thousands of people who live with ulcerative colitis. However, steroids are also toxic. Doctors today know that steroids are useful in bringing about remission, but not in maintaining remission. This knowledge, and better understanding of the drugs such as 6-MP that regulate the body's immune response, allow doctors to get people off steroids much more quickly than in the past. Today, far fewer people are steroid dependant than years ago.

  • Medications to Suppress the Immune System - These medications are known as immunosuppressive drugs. They are powerful compounds that override the body's natural immune defenses. They are widely known for their use with organ transplants to reduce the possibility of rejection. In the 1960s, physicians began experimenting with immunosuppressives for treatment of both Crohn's disease and ulcerative colitis.

    Today, doctors continue to refine the dosages used in treating inflammatory bowel disease, and in these doses the drugs are considered "immunoregulators" rather than immunosuppressives. Generally, they are used more often in Crohn's disease than ulcerative colitis.

    However, one drug, the antimetabolite 6-mercaptopurine (6-MP, sold under the trade name Purinethol), has proved very effective in helping individuals get off steroids without inducing another flare-up, and thus has reduced the number of people who are steroid-dependent in the long term.

  • Experimental Treatments - Certain nontraditional treatments also may be helpful. They include the following:
    • A compound found in fish oil, called omega-3 fatty acids, may reduce the level of a substance called leukotrienes, which play a role in inflammation. Small studies show some improvement in people with active ulcerative colitis, although not in maintaining remission.
    • Short-chain fatty acids, such as butyrate, exist in the lining of the colon. These nutrients are produced during digestion of complex carbohydrates. The intestinal lining of individuals with ulcerative colitis may not produce these nutrients. In several small trials, 35 of 41 people with ulcerative colitis benefited from SCFA enemas.
    • Rapidly metabolized steroids such as budesonide are being looked at as a way of maintaining steroid therapy for those who are steroid-dependent and who don't respond to 6-MP or cannot tolerate it, as well as for reducing the side effects of more traditional steroid treatment.
    • Nicotine gum and patches are also being studied. A significant proportion of newly diagnosed patients are former smokers who have quit within the previous four years. Nicotine has been shown to provide some protection against ulcerative colitis, and nicotine gum and patches have been shown to assist in bringing on remission after a flare-up, although not in maintaining remission.

Surgery

There is only one surgical treatment for ulcerative colitis. That is total colectomy, which is removal of the colon. This surgical procedure cures the disease, since the diseased organ is removed. But this surgery is life altering, since other methods must be used after the surgery for eliminating waste from the body.

  • Most surgery for ulcerative colitis is performed on individuals who have had the disease for many years and have suffered constant flare-ups, in whom quality of life has become severely impaired.
  • Another reason for surgery is the presence of precancerous lesions in the colon.
  • Surgery is necessary in an emergency such as perforation (a hole in the colon), severe bleeding, or toxic megacolon, a dangerous condition where the colon becomes extremely distended, causing a person to become severely ill with a high fever.
  • Surgery is also often undertaken in an urgent situation known as fulminant colitis, which involves severe diarrhea and bleeding, accompanied by high fever, that persists for many hours. In this case, doctors try to stabilize the individual with high doses of intravenous steroids before undertaking surgery.

Surgery for ulcerative colitis involves removal of the entire colon, regardless of whether all or only a portion of the colon is diseased. Because the colon is being removed, eliminating solid food waste will change. The colon acts as a storage area for waste to be held while water is reabsorbed into the body. Without the colon, stool is eliminated as a more liquid product. Depending on the type of reconstruction done after the surgery, stool is either eliminated through the anus or through an opening in the side of the abdomen called an ostomy.

There are three options for elimination of waste after a total colectomy:

  1. The first, considered the gold standard, is a standard ileostomy, in which the end of the small intestine (the terminal ileum) is brought to the abdominal wall and an opening is created in the side of the abdomen below the last rib. Intestinal contents drain continuously into a bag that lies flat against the abdomen, which is emptied when it becomes full.
  2. continent ostomy is formed when an internal pouch is created under the abdominal wall to collect waste, and a valve is created at the ostomy site. The internal pouch is drained a number of times each day by means of a rigid tube placed through the valve. In this case, no external apparatus needs to be worn.
  3. The third option is the ileo-anal pull-through. This allows elimination through the anus. In this case, the surgeon leaves the muscular sleeve of the rectum intact and attaches the ileum to this sleeve. A small J-pouch is created to hold some intestinal content.

    When this surgery works, an individual has about six to eight soft stools throughout the day. If the anal sphincter does not prove to be functional over time and bowel incontinence develops, an ostomy can be created at a later time. Ileo-anal pull-through surgery is not always successful and sometimes must be converted to an ostomy.

Need To Know:

A problem that sometimes occurs with an internal pouch is "pouchitis," which is inflammation of the pouch. Pouchitis is usually treated with 5-ASA medications. Short-chain fatty acid enemas have been shown to bring relief of pouchitis.

Alternative Treatments

Mind-body treatments can help individuals with ulcerative colitis manage pain, can contribute to a sense of well-being, and can give individuals a sense of control over a situation where, in medical terms, they have little or no control. There is, however, no proof that these therapies can undo the cellular changes done by ulcerative colitis.

Need To Know:

Alternative treatments should always be used as complementary therapy - not as a substitute - to traditional medical treatments.

Mind-body treatments include:

  • Biofeedback
  • Guided imagery
  • Hypnotherapy
  • Sound/music therapy
  • Relaxation techniques
  • Prayer and meditation

Postural therapies and exercises such as the Alexander technique, the Feldenkrais method, and the Trager method, as well as Tai Chi, can help an individual concentrate on choreographed body movements, prove relaxing, and provide a low-intensity physical workout when more active exercise is not possible.

Eastern treatments such as acupuncture and acupressure can also be used. But Chinese herbal treatments, and naturopathic or homeopathic treatments, are not recommended by medical doctors.

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Ulcerative Colitis

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From Andrew Maynard - Chair of the University of Michigan Department of Environmental Health Sciences, with help from David Faulkner - 2013 Master of Public Health graduate.