digestive disorders
Ulcerative Colitis
Treatment of Ulcerative Colitis
Dietary management andloperamide Aminosalicylates Corticosteroids Immunomodulating medications Biologic and related agents Small-molecule agents Sometimes surgery Ulcerative colitis treatment aims to control the inflammation, reduce symptoms, and replace any lost fluids and nutrients. Specific treatment depends on the severity of people's symptoms. Iron supplements may offset anemia caused by ongoing blood loss in the stool. Usually, if the large intestine is swollen, people should eat a low-fiber diet (in particular, avoiding foods such as nuts, corn hulls, raw fruits, and vegetables) to reduce injury to the inflamed lining of the large intestine. However, a high-fiber diet should be resumed once the IBD flare resolves. A diet free of dairy products may decrease symptoms and is worth trying but does not need to be continued if no benefit is noted. All people who have ulcerative colitis should take calcium andvitamin Dsupplements. Small doses ofloperamideare taken for relatively mild diarrhea. For more intense diarrhea, higher doses ofloperamidemay be needed. In severe cases, however, a doctor must closely monitor the person taking these antidiarrheal medications because of the risk of fulminant colitis. Health maintenance , particularly vaccinations and cancer screening, are important. During flares of ulcerative colitis, people should be restricted to a low-fiber diet to reduce injury to the inflamed lining of the large intestine. Once the flare has resolved, they may return to eating high-fiber foods. Aminosalicylates are medications used to reduce the inflammation of ulcerative colitis and to prevent flare-ups of symptoms. Medications such assulfasalazine,olsalazine,mesalamine, andbalsalazideare types of aminosalicylates. These medications usually are taken by mouth (orally), butmesalaminecan also be given as an enema or a suppository (rectally). Whether given orally or rectally, these medications are at best moderately effective for treating mild or moderately active disease, but they are more effective for preventing symptoms from reappearing (maintaining remission). , or an Immunomodulating medications , a Budesonideis another corticosteroid that may be used. It has fewer side effects thanprednisonebut does not work as quickly and is typically given to people whose disease is less severe. Long-term corticosteroid treatment almost always causes side effects (see sidebar). When mild or moderate ulcerative colitis is limited to the lower part of the left side of the large intestine (sigmoid colon) and the rectum, enemas or suppositories with a corticosteroid ormesalaminemay be helpful. Corticosteroid treatment is reduced and gradually stopped over several weeks. If the disease becomes severe, the person is hospitalized, and corticosteroids and fluids are given by vein (intravenously). People may still be givenmesalamine. People with heavy rectal bleeding may require blood transfusions. Immunomodulating medications modify the action of the body's immune system, decreasing its activity. Medications such asazathioprineandmercaptopurinehave been used to maintain remissions in people with ulcerative colitis who would otherwise need long-term corticosteroid treatment. These medications inhibit the function of T cells, which are an important component of the immune system. However, these medications are slow to act, and a benefit may not be seen for 1 to 3 months. They also have potentially serious side effects that require close monitoring by the doctor. Cyclosporinehas been given to some people who have severe flare-ups and have not responded to corticosteroids. Most of these people respond initially to thecyclosporine, but some may still ultimately require surgery. Tacrolimusis given by mouth. This medication has been given as short-term treatment to people whose ulcerative colitis is difficult to manage while they begin treatment withazathioprineandmercaptopurine.Tacrolimusmay help maintain remission. Biologic agents are medicines that are created by living organisms. Infliximab,which is derived from monoclonal antibodies to tumor necrosis factor (called a tumor necrosis factor inhibitor or TNF inhibitor) and given intravenously, is beneficial for some people with ulcerative colitis. This medication may be given to people who do not respond to corticosteroids or who develop symptoms whenever corticosteroid doses are lowered, despite the optimal use of other immunomodulating medications.Infliximab,adalimumab, andgolimumabare beneficial for people whose ulcerative colitis is difficult to treat or for people who depend on corticosteroids. , people must be tested for Tuberculosis (TB) and has a theoretical risk of a serious brain infection called Progressive Multifocal Leukoencephalopathy (PML) (PML) because this infection has been reported with the use of a related medication called Ustekinumabis another kind of biologic agent given to people who have moderate to severe ulcerative colitis that has not responded to TNF inhibitors or other immunomodulating medications or who are unable to tolerate these medications. The first dose is given by vein and then by injections under the skin every 8 weeks. Side effects include injection-site reactions (pain, redness, swelling), cold-like symptoms, chills, and headache. is a medication given by mouth twice a day for adults with moderate to severe ulcerative colitis. This medication is a Janus kinase (JAK) inhibitor that is not actually a biologic agent because it is created by chemical processes rather than by living organisms. However, it shares many characteristics with biologic agents, including many of their side effects. It interferes with the communication between cells that coordinate inflammation by inhibiting an enzyme (Janus kinase, or JAK). Serious side effects include increased susceptibility to infection and Pulmonary Embolism (PE) (the blocking of an artery of the lung by a blood clot). Upadacitinibis a medication for adults with moderate to severe ulcerative colitis that is given by mouth daily. It is a Janus kinase (JAK) inhibitor. This medication increases the risk for developing serious infection, heart attack, stroke, venous thrombosis (blood clot), pulmonary embolism, and arterial thrombosis (blood clot forms). is a medication given by mouth for adults with moderate to severe active ulcerative colitis. This medication should not be used by people who have had a heart attack, chest pain ( Acute Coronary Syndromes (Heart Attack; Myocardial Infarction; Unstable Angina) ), People with ulcerative proctitis,or colitis that affects only the part of the colon near the rectum, are givenmesalamineenemas. Corticosteroid andbudesonideenemas are given to people who are not helped by or cannot toleratemesalamine. People with moderate or extensive diseaseare givenmesalamineby mouth in addition tomesalamineenemas. People with severe symptoms and those who still have symptoms while usingmesalamineusually take oral corticosteroids such asprednisone.Prednisonein fairly high doses frequently induces a dramatic remission. Afterprednisonecontrols the inflammation of ulcerative colitis,sulfasalazine,olsalazine, ormesalamineoften is given to maintain the improvement. Gradually, theprednisonedosage is decreased, and ultimately theprednisoneis discontinued because prolonged corticosteroid treatment almost always causes side effects. People whose symptoms return whenprednisoneis decreased are sometimes given an immunomodulating medication (azathioprineormercaptopurine). Additionally, some people benefit frominfliximab,adalimumab,vedolizumab,golimumab,ustekinumab,tofacitinib, orozanimod. People with severe colitisare hospitalized, and high-dose corticosteroids and fluids are given intravenously. Doctors may continue to givemesalamine. People with heavy rectal bleeding may require blood transfusions. People who do not respond to these treatments within 3 to 7 days may be given intravenousinfliximab,vedolizumab, orcyclosporineor may need surgery to remove their colon. People who have severe or difficult-to-treat colitis but who do not need to be hospitalized may be giventacrolimus. People whose disease occurs suddenly, rapidly, and with great pain or who may have toxic colitis are hospitalized. All antidiarrheal medications are stopped, no food or medications are given by mouth, and doctors pass a tube through the nose and into the stomach or small intestine to remove contents from the stomach or small intestine. People are given intravenous fluids and electrolytes and high-dose intravenous corticosteroids orcyclosporine. Doctors also give antibiotics. People may be giveninfliximab. People are monitored closely for signs of infection or a perforation. People whose condition does not improve in 24 to 48 hours need immediate surgery to remove all or most of the large intestine. To prevent symptoms from reappearing (that is, to maintain remission), people continue to takemesalamineby mouth or as an enema indefinitely because stopping this maintenance regimen often allows the disease to return (called relapse). Studies suggest that a combination of oral and rectalmesalaminetreatment is significantly more effective than either treatment alone. People who cannot stop taking corticosteroids are given immunomodulating medications (azathioprineormercaptopurine), TNF inhibitors (infliximab,adalimumab, orgolimumab),tofacitinib,upadacitinib,vedolizumab,ustekinumab, orozanimodor a combination of immunomodulating medications and TNF inhibitors. About 30% of people with extensive ulcerative colitis require surgery. Emergency surgery may be necessary for sudden life-threatening attacks with massive bleeding, perforation, or fulminant colitis. Sometimes surgery is needed even when there is no emergency reason for surgery. These situations include chronic colitis that is disabling or that constantly requires high doses of corticosteroids, cancer, and narrowing of the large intestine or growth retardation in children. Complete removal of the large intestine, rectum, and anus (total proctocolectomy) permanently cures ulcerative colitis, restores life expectancy to normal, and eliminates the risk of colon cancer. However, inflammation develops in the small intestine in about 25% of people after surgery even though their small intestine was not previously affected. Because the rectum and anus are removed, people must have a permanent ileostomy. In an ileostomy, a surgeon brings the end of the lowest portion of the small intestine (ileum) out through an opening in the abdominal wall (stoma). People who have an ileostomy must always wear a plastic bag (ileostomy bag) over the opening to collect the stool that comes out. An ileostomy used to be the traditional price of this cure. However, various alternative procedures are now available, and the most common one is a procedure called proctocolectomy with ileal pouch-anal anastomosis (IPAA). In this procedure, the large intestine and most of the rectum are removed, and a small reservoir (pouch) is created out of the small intestine and attached to the remaining rectum just above the anus. Because the muscles of the anus (anal sphincter) are not removed, this procedure allows people to remain in control of their bowels (continence). However, because a small amount of tissue of the rectum can remain, the risk of cancer is significantly decreased but not eliminated. A common complication of IPAA is inflammation of the reservoir (called pouchitis). To treat pouchitis, doctors give antibiotics. Most cases of pouchitis can be controlled with medications, but a small percentage cannot. For these cases, doctors create an ileostomy to correct the problem. For people with ulcerative proctitis, surgery is rarely needed, and life expectancy is normal. In some people, though, the symptoms may be very difficult to treat. 