The goal of treatment is to reduce inflammation in the colon, ultimately resulting in remission. About 70 percent of patients respond well to drug therapy and do go into remission. While surgery to remove all or part of the colon does cure UC, it's only necessary for patients who are unresponsive to medications and have severe symptoms, life-threatening complications, or colon cancer. Treatment of UC is very individualized, based on the needs of the patient, the extent of the disease, and each patient's response to different medications.
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The drugs available to treat UC fall into three basic categories: the aminosalicylate compounds; systemic and topical corticosteroids; and immune modifying drugs. These medications are available in a variety of forms, both as pills and topical remedies, as well as medications injected into the veins. All are aimed at reducing inflammation in the colon and rectum. The type and combination of medications a doctor chooses depend on the extent of the disease.
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Compounds of 5-aminosalicyclic acid (5-ASA) are also called mesalamine. They are chemical cousins to aspirin (acetylsalicylic acid) but differ in their effects on UC. Aspirin is not effective in treating ulcerative colitis and may actually worsen or trigger an attack. However, 5-ASA compounds can be very effective at treating attacks of UC as well as maintaining remission as long as these drugs reach the portion of the colon or rectum that is inflamed.
Topical 5-ASA medications given via the rectum, such mesalamine suppositories or Rowasa enemas, are used to treat ulcerative proctitis or inflammation of the rectum and sigmoid colon, called proctosigmoiditis. But these rectal preparations do not reach higher portions of the colon. As a result, about two thirds of patients are likely to be prescribed some type of 5-ASA drug taken orally, depending on the extent of their UC. Among people with mild to moderate UC involving all of the left side of the colon, or the entire colon, often a rectal preparation and an oral 5-ASA compound are prescribed.
Because the stomach absorbs pure 5-ASA before it ever reaches the inflamed colon, medications that are used to treat UC are modified 5-ASA compounds. They link the 5-ASA molecule to another compound, which acts as a carrier to prevent the medication from being absorbed in the stomach before it can pass through to the colon. For example, one of the first generation of these medications, sulfasalazine, is a 5-ASA molecule linked to a sulfa antibiotic called sulfapyridine. The antibiotic acts as a carrier to prevent rapid stomach absorption. When sulfasalazine reaches the colon, bacteria in the colon break the linkage between the two molecules. The sulfa antibiotic is absorbed by the body and excreted in urine, but most of the 5-ASA remains in the colon to treat UC.
Sulfasalazine has been used successfully for many years to treat patients with mild to moderate UC and for long periods of time to maintain remissions. However, it is associated with multiple side effects, including nausea, heartburn, headache, skin rashes, lowered white cell count, and in rare cases, hepatitis and kidney inflammation. The drug may temporarily lower sperm counts in men. Since high doses may be required, the drug can cause stomach upsets.
Many of the side effects associated with sulfasalazine are thought to be due to the sulfa antibiotic carrier. Therefore, most patients with UC today instead take medications within a group of newer 5-ASA compounds that deliver 5-ASA to the colon without using sulfapyridine as a carrier molecule. One of these drugs, mesalamine (Asacol), is a tablet consisting of 5-ASA surrounded by a resin coating that prevents rapid stomach absorption. Once Asacol is in the colon, the resin dissolves, releasing 5-ASA into the colon. The drug induces remission in those with mild to moderate UC and has been used safely for prolonged periods to keep symptoms at bay. Other 5-ASA sulfa-free compounds are olsalazine (Dipentum), balsalazide (Colazal), and other mesalamine formulations (Pentasa, Salofalk).
While side effects from sulfa-free 5-ASA compounds are generally less than those from sulfasalazine, patients allergic to aspirin should not take these drugs. People with kidney disease should do so cautiously. Blood tests for kidney function are recommended before starting treatment with these medications. Worsening of diarrhea, cramps, and abdominal pain accompanied by rash and fever may indicate an allergic reaction to 5-ASA compounds.
Corticosteroids have been used for many years to treat moderate to severe ulcerative colitis. These drugs include prednisone, prednisolone, and hydrocortisone. Topical corticosteroids, such as hydrocortisone foam or enemas, act very quickly on local inflammation and may be prescribed along with an oral 5-ASA compound.
Systemic corticosteroids are powerful drugs given orally or intravenously that have an anti-inflammatory effect throughout the body. They do not require direct contact with the inflamed tissues to work and are much faster-acting than the 5-ASA compounds. Patients may experience improvement in symptoms in a few days. Short courses of systemic corticosteroids usually have mild side effects, but problems increase with dosage and duration of use. Long term, high-dose corticosteroids result in potentially serious side effects. These may include increased body hair, diabetes, weight gain, high blood pressure, cataracts, glaucoma, increased susceptibility to infections, mood swings, and osteoporosis with accompanying fractures. One of the most serious side effects associated with long-term use of these drugs is call aseptic necrosis of the hip joints, or the death of bone tissue in the hips, ultimately requiring hip replacement. Aseptic necrosis of the knee joints has also been reported.
Systemic corticosteroids are generally prescribed if a patient's ulcerative colitis does not respond to other medications, or is severe-that is, the person is suffering six or more bloody stools per day, low blood pressure, and other systemic complications.
Immune modulators are medications that suppress the body's immune system, thereby reducing the natural immune response to injury-inflammation. Some of these drugs include azathioprine, 6-mercaptopurine, cyclosporine, and methotrexate. Recently, infliximab (Remicade) was approved by the FDA for treatment of UC. These are powerful medications, some used to treat leukemia and other cancers and to prevent rejection of transplanted organs. They have a myriad of side effects, including organ toxicity, infection, pneumonia, and bone marrow suppression. However, immune modifying drugs are become increasingly important treatments for patients with severe ulcerative colitis who do not respond to other treatments.
Surgery for ulcerative colitis is necessary only in patients who do not respond to medications or who develop life-threatening complications associated with UC. Elective surgery to remove the colon cures severe ulcerative colitis and has a very low mortality rate of less than 1 percent. However, there are some significant challenges for patients who must opt for surgery.
The standard surgical procedure involves total removal of the colon and rectum with formation of an opening from the small intestine to the outside of the body, called a "Brooke ileostomy." An ileostomy provides a new path for waste to leave the body once the colon and rectum are removed. The patient attaches a double-faced adhesive ring to the skin and then an opaque sack that collects material from the small intestine.
The "Koch pouch" is an alternative to the Brooke ileostomy. In this surgery, an internal reservoir, or pouch, is created from a portion of the small intestine and a nickel-size nipple valve opens from it into the lower abdominal wall. The patient attaches a catheter to the valve to drain the pouch. The main disadvantage to this surgery is that the valve requires repair in two to five years in 25 to 30 percent of patients.
The most popular alternative to ileostomy is the creation of a new rectum from the small bowel and attachment of the internal reservoir or pouch to the anal canal. This procedure, called an "ileal pouch-anal anastomosis," is often done in several phases or operations and involves creation of a temporary ileostomy. After healing, the temporary ileostomy is closed and patients can defecate through their anus. After one year, most patients have five bowel movements per day and incontinence is uncommon, though some people experience incontinence at night. About 25 percent of patients who opt for this procedure develop pouchitis, or inflammation of the small, internal pouch. This can usually be treated by short courses of oral antibiotics.
Last reviewed on 6/4/09
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