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Ulcerative Colitis

Last updated on October 8, 2021

Ulcerative ColitisMild to Moderate Disease

The first line of drug therapy for the patient with mild to moderate colitis is oral sulfasalazine or an oral mesalamine derivative, or topical mesalamine or steroids for distal disease.

When given orally, usually 4 g/day, up to 8 g/day of sulfasalazine is required to attain control of active inflammation. Sulfasalazine therapy should be instituted at 500 mg/day and increased every few days up to 4 g/day or the maximum tolerated.

Oral mesalamine derivatives are reasonable alternatives to sulfasalazine for treatment of ulcerative colitis but they are not more effective than sulfasalazine.

Steroids have a place in the treatment of moderate to severe ulcerative colitis that is unresponsive to maximal doses of oral and topical mesalamine. Prednisone up to 1 mg/kg/day may be used for patients who do not have an adequate response to sulfasalazine or mesalamine.

Steroids and sulfasalazine appear to be equally efficacious; however, the response to steroids may be evident sooner.

Rectally administered steroids or mesalamine can be used as initial therapy for patients with ulcerative proctitis or distal colitis.

Transdermal nicotine in the highest tolerated dose improved symptoms of patients with active ulcerative.

TABLE. Mesalamine Derivatives for Treatment of Inflammatory Bowel Disease
Product Trade Name(s) Formulation Dose/Day Site of Action
Sulfasalazine Azulfidine Tablet 4– 6 g Colon
Mesalamine Rowasa, Salofalk, Claversal, Pentasa Enema 1– 4 g Rectum, terminal colon
Asacol Mesalamine tablet coated with Eudragit-S (delayed-release acrylic resin) 2.4– 4.8 g Distal ileum and colon
Pentasa Mesalamine capsules encapsulated in ethylcellulose microgranules 2– 4 g Small bowel and colon
Olsalazine Dipentum Dimer of 5-aminosalicylic acid oral 1.5– 3 g Colon
Balsalazide Colazal capsule 6.75 g Colon

Severe or Intractable Disease

Patients with uncontrolled severe colitis or incapacitating symptoms require hospitalization for effective management. Most medication is given by the parenteral route.

With severe colitis, there is a much greater reliance on parenteral steroids and surgical procedures. Sulfasalazine or mesalamine derivatives have not been proven beneficial for treatment of severe colitis.

Steroids have been valuable in the treatment of severe disease because the use of these agents may allow some patients to avoid colectomy. A trial of steroidsis is warranted in most patients before proceeding to colectomy, unless the condition is grave or rapidly deteriorating.

Continuous intravenous infusion of cyclosporine (4 mg/kg/day) is recommended for patients with acute severe ulcerative colitis refractory to steroids.

Maintenance of Remission

Once remission from active disease has been achieved, the goal of therapy is to maintain the remission.

The major agents used for maintenance of remission are sulfasalazine (2 g/day) and the mesalamine derivatives, although mesalamine is not as effective as sulfasalazine.

Steroids do not have a role in the maintenance of remission with ulcerative colitis because they are ineffective. Steroids should be gradually withdrawn after remission is induced (over 3 to 4 weeks). If they are continued, the patient will be exposed to steroid side effects without likelihood of benefits.

Maintenance of remission is well documented up to 1 year and may last as long as 3 years.

Azathioprine is effective in preventing relapse of ulcerative colitis for periods of up to 2 years. However, 3 to 6 months may be required for beneficial effect.

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