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Ulcerative Colitis in Children Medication

  • Author: Judith R Kelsen, MD; Chief Editor: Carmen Cuffari, MD  more...
 
Updated: Nov 19, 2015
 

Anti-inflammatory Agents

Class Summary

These drugs are used to maintain remission and to induce remission of mild flares of disease. The mainstay of outpatient management is anti-inflammatory therapy with 5-a minosalicylic acid (5-ASA) preparations.

Sulfasalazine (Azulfidine)

 

Sulfasalazine was the first 5-aminosalicylic acid preparation available for the treatment of ulcerative colitis (UC). It is useful in the management of ulcerative colitis and acts locally in the colon to decrease the inflammatory response and systemically inhibits prostaglandin synthesis

Mesalamine (Asacol, Pentasa, Rowasa)

 

Mesalamine is DOC to maintain remission. Mesalamine is provided as a controlled-release capsule (Pentasa) or enteric-coated tablet (Asacol). Begin with a low dose, and increase the dose if adverse effects (eg, headache, diarrhea) do not develop. It is also available as an enema or suppository for rectal administration. Asacol is the only oral product approved for use in children aged 5 years or older. The dose of Asacol in children is dependent on weight.

The currently approved PO mesalamine products in the United States differ only in the mechanism of drug delivery. Asacol has mesalamine within a Eudragit-S coating that dissolves and releases the mesalamine at pH 7, which typically occurs in the terminal ileum. Pentasa is 5-ASA in ethylcellulose and has a time-release coating. Its release begins at the pylorus. Rectal dosage forms deliver high concentrations of mesalamine to the left colon as high as the splenic flexure (enema with 30 min retention) or to the rectum for use in proctitis (supp). Although effective, mesalamine is associated with a relatively high relapse rate upon discontinuation.

Balsalazide (Colazal)

 

Balsalazide is a prodrug that is converted into 5-aminosalicyclic acid through bacterial azoreduction. Metabolites of the drug may decrease inflammation by blocking production of arachidonic acid metabolites in the colon mucosa.

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Immunosuppressive Agents

Class Summary

These drugs are used in steroid-refractory or steroid-dependent patients.

6-Mercaptopurine (Purinethol)

 

6-Mercaptopurine is a purine analog that inhibits purine ribonucleotide synthesis and cell proliferation. It alters immune response through effects on natural killer cells and cytotoxic T cells.

Azathioprine (Imuran)

 

Azathioprine is rapidly converted to 6-mercaptopurine in vivo. It antagonizes purine metabolism and inhibits synthesis of DNA, RNA, and proteins. It may decrease proliferation of immune cells, which lowers autoimmune activity.

Cyclosporine (Sandimmune, Neoral)

 

Cyclosporine, also called cyclosporin A, is used to treat severe colitis refractory to corticosteroids. One must strongly consider surgical colectomy. It may cause irreversible nephrotoxicity, seizures, and opportunistic infections.

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Corticosteroids

Class Summary

These drugs are used to induce the remission of acute exacerbations. Acute flares of moderate-to-severe ulcerative colitis in the pediatric population tend to respond well to corticosteroids, but numerous adverse effects limit long-term use.

Prednisone (Deltasone, Orasone)

 

Used for short-term exacerbations. It has a direct effect on inflammation, including decreased release of inflammatory cytokines; inhibition of phospholipase, which, in turn, inhibits arachidonic acid liberation from membranes; and inhibition of neurofibromatosis (NF)–kappa-beta function.

Methylprednisolone (Solu-Medrol)

 

Methylprednisolone decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability. This agent is administered intravenously in severe cases.

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TNF Inhibitors

Class Summary

Tumor necrosis factor (TNF) is a cytokine; 2 forms with similar biologic properties have been identified. TNF-alpha, or cachectin, is produced predominantly by macrophages. TNF-beta, or lymphotoxin, is produced by lymphocytes. TNF is but one of many cytokines involved in the inflammatory cascade that may contribute to symptoms.

Infliximab (Remicade)

 

Infliximab neutralizes cytokine TNF-alpha and inhibits its binding to TNF-alpha receptor. Mix in 250 mL 0.9% NaCl and infuse IV over 2 hours. A low-protein-binding filter (1.2 µm or smaller) must be used. It is indicated to reduce signs and symptoms, to induce and maintain clinical remission and mucosal healing, and to eliminate corticosteroid use in adults with moderate-to-severe active UC who have had an inadequate response to conventional therapy. In September 2011, the FDA approved infliximab for UC in children.

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Contributor Information and Disclosures
Author

Judith R Kelsen, MD Assistant Professor of Pediatrics, University of Pennsylvania School of Medicine; Attending Physician, Division of Gastroenterology, Hepatology and Nutrition, The Children’s Hospital of Philadelphia

Judith R Kelsen, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Study of Liver Diseases, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

Coauthor(s)

Petar Mamula, MD Associate Professor, Department of Pediatrics, Division of Gastroenterology and Nutrition, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine

Petar Mamula, MD is a member of the following medical societies: American Academy of Pediatrics, American Society for Gastrointestinal Endoscopy, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

Chief Editor

Carmen Cuffari, MD Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Prometheus Laboratories for speaking and teaching; Received honoraria from Abbott Nutritionals for speaking and teaching.

Acknowledgements

Robert Baldassano, MD, Director, Center for Pediatric Inflammatory Bowel Disease, Children's Hospital of Philadelphia; Professor, Department of Pediatrics, Division of Gastroenterology and Nutrition, University of Pennsylvania School of Medicine

Robert Baldassano, MD is a member of the following medical societies:Alpha Omega Alpha, American Academy of Pediatrics, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Abbott Inc, Consulting fee, Consulting

Liz D Dancel, MD Intern, Department of Pediatrics, Greenville Hospital System University Medical Center

Disclosure: Nothing to disclose.

Jonathan Markowitz, MD Assistant Professor, Department of Pediatrics, Inpatient Gastroenterology, Division of Gastroenterology and Nutrition, University of Pennsylvania School of Medicine; Director, The Children's Hospital of Philadelphia.

Jonathan Markowitz is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

David A Piccoli, MD Chief of Pediatric Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia; Professor, University of Pennsylvania School of Medicine

David A Piccoli, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Jorge H Vargas, MD Professor of Pediatrics and Clinical Professor of Pediatric Gastroenterology, University of California, Los Angeles, David Geffen School of Medicine; Consulting Physician, Department of Pediatrics, University of California at Los Angeles Health System

Jorge H Vargas, MD is a member of the following medical societies: American Liver Foundation, American Society for Gastrointestinal Endoscopy, American Society for Parenteral and Enteral Nutrition, Latin American Society of Pediatric Gastroenterology, Hepatology & Nutrition, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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Ulcerative colitis. Specimen from colectomy reveals diffusely hemorrhagic granular mucosa in a continuous distribution.
Histological section: diffuse inflammatory process, limited to mucosa and superficial portion of the submucosa (full thickness biopsy,staining, magnification).
Histological section: diffuse inflammatory process, limited to mucosa and superficial portion of the submucosa (full thickness biopsy,staining, magnification).
 
 
 
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