eMedicine Specialties > Gastroenterology > Colon

Ulcerative Colitis: Treatment & Medication

Author: Tri H Le, MD, Assistant Professor of Medicine, Division of Gastroenterology and Hepatology, Penn State Milton S Hershey Medical Center
Contributor Information and Disclosures

Updated: Aug 7, 2008

Treatment

Medical Care

An appropriate medical regimen for ulcerative colitis is determined by the severity and the extent of disease. See Medication. 

Prior to initiating therapy, an accurate assessment is needed; this assessment should include a thorough history and physical examination. A colonoscopy is preferable.

See related CME at Advances in Ulcerative Colitis.

Surgical Care

Considerations for total colectomy are as follows:

  • Refractory disease with failure to medical therapy
  • Evidence of carcinoma or dysplasia
  • Severe hemorrhage
  • Fulminant colitis not responsive to treatment
  • Toxic megacolon
  • Perforation (free or walled-off)
  • Obstruction and stricture with suspicion for cancer
  • Systemic complications from medications, particularly steroids
  • Failure to thrive in children

Consultations

  • Gastroenterologist
  • Consultation with a surgeon for severe or fulminant colitis

Diet

  • No specific diet restrictions are required for patients with ulcerative colitis. However, many patients with ulcerative colitis can have concurrent lactose intolerance.
  • No specific diet can maintain remission.
  • Elemental nutrition and parenteral nutrition have no primary therapeutic role in ulcerative colitis, although parenteral nutrition is often used in patients who are severely ill as effective nutritional support.

Medication

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Tumor necrosis factor (TNF) inhibitors

These agents prevent the endogenous cytokine from binding to cell surface receptor and exerting biological activity.


Infliximab (Remicade)

Infliximab is a chimeric mouse-human monoclonal antibody to TNF. It binds free and membrane-bound TNF and thus prevents the cytokine from binding to its cell surface receptor and exerting biological activity.
Infliximab is indicated for the treatment of moderate-to-severe active ulcerative colitis in patients who have experienced inadequate response to conventional therapy. It has been shown to reduce signs and symptoms, to achieve clinical remission and mucosal healing, and to eliminate corticosteroid use

Adult

5 mg/kg IV infusion at 0, 2, and 6 wk as induction therapy and followed by 5 mg/kg IV infusion q8wk as maintenance regimen

Pediatric

Not established

May decrease the effect of vaccines (dead organisms); may enhance adverse effects of vaccines (live organisms)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May adversely affect normal immune responses and allow development of superinfections; reactivation of latent TB has been reported in patients with previous exposure to TB; tuberculin skin test is recommended prior to therapy; may increase the risk of lymphoma; worsening of congestive heart failure has been reported in patients with decreased left ventricular function; reaction (acute or delayed) to infliximab can be frequent (can be reduced by avoiding episodic dosing and use of a concomitant immunomodulator)

Immunomodulators

These agents regulate key factors of the immune system.


Azathioprine (Imuran)

Effective as a steroid-sparing or steroid-reducing agent. Effective as maintenance agent. Can have delayed onset of action of up to 3-6 mo.

Adult

2-3 mg/kg/d PO

Pediatric

Not established

Toxicity increases with allopurinol; concurrent use with ACE inhibitors may induce severe leukopenia; may increase levels of methotrexate metabolites and decrease effects of anticoagulants, neuromuscular blockers, and cyclosporine

Documented hypersensitivity; low levels of serum thiopurine methyltransferase (TPMT); patients who were treated with alkylating agents (eg, cyclophosphamide, chlorambucil, melphalan)

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Increases risk of neoplasia in general but is controversial among patients with inflammatory bowel disease; caution in patients with liver disease and renal impairment; hematologic toxicities may occur; check TPMT level prior to therapy and monitor liver, renal, and hematologic function; pancreatitis rarely is associated


Cyclosporine (Neoral, Sandimmune)

Effective as a means of avoiding surgery in patients with severe ulcerative colitis refractory to intravenous corticosteroids.

Adult

2-4 mg/kg/d IV infusion (can be switched to PO qd dose doubled that of IV dose as "bridge" therapy as outpatient)

Pediatric

Administer as in adults

Carbamazepine, phenytoin, isoniazid, rifampin, and phenobarbital may decrease cyclosporine concentrations; azithromycin, itraconazole, nicardipine, ketoconazole, fluconazole, erythromycin, verapamil, grapefruit juice, diltiazem, aminoglycosides, acyclovir, amphotericin B, and clarithromycin may increase cyclosporine toxicity; acute renal failure, rhabdomyolysis, myositis, and myalgias increase when taken concurrently with lovastatin

Documented hypersensitivity; uncontrolled hypertension or malignancies; do not administer concomitantly with PUVA or UVB radiation in psoriasis because it may increase risk of cancer

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Evaluate renal and liver functions often by measuring BUN, serum creatinine, serum bilirubin, and liver enzymes; may increase risk of infection and lymphoma; increases risk of seizures


6-Mercaptopurine (Purinethol)

Effective as a steroid-reducing or steroid-sparing agent. Effective in maintaining remission. Can have a delayed onset of action of up to 3-6 months.

Adult

1-1.5 mg/kg/d PO

Pediatric

Not established

Toxicity increases when administered with allopurinol; hepatic toxicity increases when used in combination with doxorubicin

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Exercise caution in patients diagnosed with renal or hepatic impairment; patients on this medication have a high risk of developing pancreatitis, monitor for myelosuppression

Antimicrobials

Antibiotics have not been shown to provide consistent benefits from several controlled trials for the treatment of active ulcerative colitis. Thus, they are usually administered on an empiric basis in patients with severe colitis in whom they may help with averting a life-threatening infection. They have been shown to be effective for the treatment of pouchitis after ileoanal pouch anastomosis procedure.


Ciprofloxacin (Cipro)

Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, Staphylococcus epidermidis, and most gram-negative organisms but no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth.

Adult

500 mg PO bid
400 mg IV bid

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in patients with renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy


Metronidazole (Flagyl)

Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents (except for C difficile enterocolitis).

Adult

Loading dose: 15 mg/kg (or 1 g for 70-kg adult) IV over 1 h
Maintenance dose: 6 h following loading dose, infuse 7.5 mg/kg (or 500 mg for 70-kg adult) over 1 h q6-8h; not to exceed 4 g/d

Pediatric

Administer as in adults, using body weight

May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity of metronidazole; disulfiram reaction may occur with orally ingested ethanol

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in patients with hepatic disease; monitor for seizures and development of peripheral neuropathy

Corticosteroids

Used in moderate-to-severe active cases for induction of remission. They have no benefit in maintaining remission; long-term use can cause adverse effects.


Methylprednisolone (Solu-Medrol, Depo-Medrol, Medrol)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability. Administered intravenously in severe cases.

Adult

80 mg IV q8h; dose may vary

Pediatric

60 mg IV q8h in severe or fulminant cases; dose may vary

Mutual inhibition of metabolism occurs with concomitant use of cyclosporine and methylprednisolone; convulsions have been reported when these medicines were used together; drugs that induce hepatic enzymes (eg, phenobarbital, phenytoin, rifampin) may increase clearance of methylprednisolone; troleandomycin and ketoconazole may inhibit the metabolism of methylprednisolone; may increase the clearance of long-term high-dose aspirin; variable effect on oral anticoagulants

Documented hypersensitivity; premature infants; systemic fungal infections

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Acne, striae, and hirsutism; cataracts; glaucoma; hypertension; glucose intolerance; adrenal suppression; osteoporosis and osteonecrosis; growth retardation in children; masking or induction of intestinal perforation


Prednisone (Deltasone, Orasone, Meticorten)

Effective for the treatment of active moderate-to-severe ulcerative colitis. Not efficacious as a maintenance therapy.
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

Adult

40-60 mg/d PO as induction for 7-14 d followed by gradual taper by 5 mg/wk of prednisone to dose of 20 mg/d and then 2.5-5 mg/wk below 20 mg/d

Pediatric

4-5 mg/m2/d PO; alternatively, 0.05-2 mg/kg PO divided bid/qid

Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics

Documented hypersensitivity; peptic ulcer disease; hepatic dysfunction; GI disease; connective tissue infections; viral infections; fungal or tubercular skin infections

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use

5-aminosalicylic Acid Derivative

These agents have anti-inflammatory effects.


Sulfasalazine (Azulfidine, EN-Tabs)

Useful in treating mild-to-moderate ulcerative colitis and maintaining remission. It acts locally in the colon to reduce the inflammatory response and systemically inhibits prostaglandin synthesis.

Adult

Induction: 4-6 g/d in PO divided dose
Maintenance: 2-4 g/d PO in divided dose

Pediatric

<2 years: Not established
>2 years: 40-75 mg/kg/d PO q4-6h, not to exceed 6 g/d; followed by maintenance dose of 30-50 mg/kg/d q4-8h, not to exceed 2 g/d

The absorption of digoxin and folic acid may be decreased; conversely, effect of anticoagulants and oral hypoglycemic agents may be increased; may increase the risk of myelosuppression due to TPMT inhibition when taking with azathioprine or mercaptopurine

Documented hypersensitivity to sulfasalazine, sulfa drugs, or salicylates; porphyria; GI or GU obstruction; pregnancy (at term)

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Use with caution in patients with renal or hepatic impairment, blood dyscrasias, G6PD deficiency, urinary obstruction, or allergies/asthma; dose-dependent adverse effects are common, such as anorexia, nausea, vomiting, diarrhea, and gastric distress; other common adverse effects include headache, photosensitivity, and reversible oligospermia


Balsalazide (Colazal)

Useful in the treatment of mild-to-moderate ulcerative colitis and maintaining remission.
Prodrug converted into 5-aminosalicylic acid through bacterial azoreduction. Ninety nine percent of drug is delivered to the colon.

Adult

750 mg cap PO (induction: 6.75 g/d; maintenance: 3-6 g/d); tid dosing for induction and bid dosing for maintenance

Pediatric

Not established

May decrease absorption of cardiac glycosides; may decrease metabolism of thiopurine analogs

Documented hypersensitivity to balsalazide and salicylates

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

May exacerbates colitis; caution in renal impairment; safety and efficacy of long-term use (>12 wk) not established


Mesalamine (Asacol, Pentasa, Lialda, Rowasa, Canasa)

Useful for the treatment of mild-to-moderate ulcerative colitis and maintaining remission. Better tolerated and less adverse effects as compared to sulfasalazine.
Topical agents (Rowasa enema & Canasa suppository) are typically used in patients with distal colitis.

Adult

Asacol: 400-mg tab (induction: 2.4-4.8 g/d; maintenance is similar to induction) PO tid dosing
Pentasa: 250 mg/500 mg cap (induction: 2-4 g/d; maintenance is similar to induction) PO qid dosing
Lialda : 1.2 g tab (induction only: 2.4-4.8 g/d) PO qd dosing
Rowasa enemas: 4 g/60 mL (induction: 4 g PR qd; maintenance can be less frequent) PR qhs dosing or less frequent for maintenance
Canasa: 500 mg/1000 mg (induction: 1 g PR qd; maintenance is similar to induction) PR bid or qd dosing

Pediatric

Not established

May decrease the absorption of digoxin; can increase the risk for myelosuppression when taken with azathioprine, mercaptopurine, or thioguanine due to inhibition of TPMT

Hypersensitivity to mesalamine, sulfasalazine, and salicylates

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

May cause worsening of colitis; caution in patients with renal impairment; minimal change nephropathy and interstitial nephritis reported; elderly patients may have difficulty administering and retaining enemas

More on Ulcerative Colitis

Overview: Ulcerative Colitis
Differential Diagnoses & Workup: Ulcerative Colitis
Treatment & Medication: Ulcerative Colitis
Follow-up: Ulcerative Colitis
Multimedia: Ulcerative Colitis
References
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References

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Further Reading

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Keywords

ulcerative colitis, UC, inflammatory bowel disease, IBD, Crohn’s disease, Crohn disease, irritable bowel syndrome, IBS, colonic inflammation, rectal inflammation, toxic megacolon, ileus, diverticulitis, primary sclerosing cholangitis, rectal bleeding, bloody bowel movements

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Contributor Information and Disclosures

Author

Tri H Le, MD, Assistant Professor of Medicine, Division of Gastroenterology and Hepatology, Penn State Milton S Hershey Medical Center
Tri H Le, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society of Gastrointestinal Endoscopy, and Crohns and Colitis Foundation of America
Disclosure: Nothing to disclose.

Medical Editor

Anil Minocha, MD, FACP, FACG, Clinical Professor, School of Pharmacy, Professor of Medicine, Director of Digestive Diseases, Medical Director of Nutrition Support, Medical Director of Gastrointestinal Endoscopy, Internal Medicine Department, University of Mississippi Medical Center
Anil Minocha, MD, FACP, FACG is a member of the following medical societies: American Academy of Clinical Toxicology, American Association for the Study of Liver Diseases, American College of Forensic Examiners, American College of Gastroenterology, American College of Physicians, American Federation for Clinical Research, American Gastroenterological Association, and American Society of Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Noel Williams, MD, Professor Emeritus, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Professor, Department of Internal Medicine, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
Noel Williams, MD is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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