Mild 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|
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.