Medical treatment of UC generally focuses on two separate goals:
- the induction of remission (making a sick person well), and
- the maintenance of remission (preventing relapse).
Surgery is also a treatment option for UC and will be discussed separately. Medication choices can be grouped into four general categories:
- immunomodulators, and
Aminosalicylates are a group of anti-inflammatory medications (sulfasalazine, mesalamine, olsalazine, and balsalazide) used for both the induction and maintenance of remission in mild to moderate UC. These medications are available in both oral formulations and rectal preparations (suppositories and enemas) and work on the lining of the colon to decrease inflammation. They are generally well tolerated. The most common side effects include nausea and rash. Rectal formulations of mesalamine (enemas and suppositories) are generally used for those patients with disease at the end of their colon.
Steroids (prednisone) are an effective medication for the induction of remission in moderate to severe UC and are available in oral, rectal, and intravenous (IV) forms. Steroids are absorbed into the bloodstream and have a number of severe side effects that make them unsuitable for chronic use to maintain remission. These side effects include cataracts, osteoporosis, mood effects, an increased susceptibility to infection, high blood pressure, weight gain, and an underactive adrenal gland.
Immunomodulators include medications such as 6-mercaptopurine and azathioprine. These are taken in pill form and absorbed into the bloodstream. They are effective for maintenance of remission in moderate to severe UC but are slow to work and can take up to two to three months to reach their peak effect. Because of this, these medications are often combined with other medications (such as steroids) in patients who are very ill. These medications require frequent blood work as they can cause liver test abnormalities and low white blood cell counts, both of which are reversible when the medication is stopped. Adverse reactions can include nausea, rash, liver and bone marrow toxicity, pancreatitis, and, rarely, lymphoma.
Biologic agents are medications given by infusion or injection that are used to treat moderate to severe UC. There are two classes of biological therapies that treat UC.
- First is the class of anti-TNF therapies. These antibodies target an inflammatory protein called “TNF” and have been shown to be effective for induction and maintenance of remission of UC. These include infliximab (Remicade®, Inflectra® and Renflexis®), adalimumab (Humira®) and golimumab (Simponi®). The side effects of these medicines may include an allergic reaction to the medication called a "hypersensitivity reaction." There are also rare risks of serious infections with these medications. Lymphoma is a rare risk of these therapies as well, but more recent scientific studies suggest that this may not be directly related to these medications, but instead primarily related to the thiopurine immune suppressants (see above.)
- The second class of biological therapy that treats UC is a medication that blocks the body’s ability to send white blood cells (part of your immune system) to the bowel and cause inflammation. There is currently one therapy that is in this class (vedolizumab (Entyvio®), and it has been shown to induce and maintain remission of UC.
Tofacitinib is a more recently available oral medication (not a biological therapy) that also can induce and maintain remission of UC. Tofacitinib (Xeljanz®) works by blocking an enzyme that is responsible for turning on inflammation. This treatment can work quickly but may increase your cholesterol level or increase the risk of developing shingles infection (related to chicken pox). This risk can be minimized by having a vaccination for the shingles virus (varicella zoster).
As with all medications, you should discuss the risks and benefits with your doctor.
Other medications used less frequently for UC include cyclosporine and tacrolimus. These agents are sometimes used in those rare cases of severe UC that are not responsive to steroids. Side effects of these agents include infections and kidney problems. These agents are offered at a limited number of hospitals and are usually used for a short period of time as a bridge to other maintenance therapies such as azathioprine, 6-mercaptopurine or vedolizumab.
Taking Medication for UC as Prescribed: No matter which medical therapy you and your doctor decide upon, adherence with the prescribed course is essential. No medical therapy can work if it is not taken, and failure to take your medications can lead to unnecessary escalation of therapy if it is not brought to the attention of your doctor. Because many of the complications associated with UC are related to ongoing disease activity, good medication adherence may minimize these risks.