Ulcerative colitis (UC) is a chronic inflammatory bowel disease that requires ongoing medical management. The primary goal of treatment is to reduce inflammation and alleviate symptoms, improving quality of life. This guide details the main classes of medications used to manage UC, their mechanisms, and key considerations for patients.
Understanding the Approach to Medication
The treatment of UC is often stepped, starting with milder therapies and escalating if necessary. The choice of medication depends on disease severity, individual patient responses, and potential side effects. It’s crucial to work closely with a gastroenterologist to determine the most appropriate regimen.
Aminosalicylates: First-Line Treatment
Aminosalicylates, such as mesalamine, sulfasalazine, olsalazine, and balsalazide, are frequently the initial medication for mild to moderate UC. These drugs reduce inflammation directly in the gastrointestinal (GI) tract.
- Mesalamine is available in oral (tablet, capsule) and rectal (suppository, enema) formulations. It’s used for both active symptoms and long-term maintenance.
- Sulfasalazine carries a higher risk of allergic reactions and can affect fertility in men.
Roughly 50% of UC patients achieve remission with aminosalicylates, but common side effects include nausea, headache, joint stiffness, and rash.
Corticosteroids: For Short-Term Relief
Corticosteroids (prednisone, budesonide, hydrocortisone) are powerful anti-inflammatory drugs used to induce remission quickly, especially in severe cases. However, they are not recommended for long-term use due to significant side effects.
- Budesonide is often preferred due to fewer systemic side effects compared to other corticosteroids.
- Prolonged steroid use can lead to weight gain, mood swings, infections, high blood sugar, and osteoporosis.
Steroids should be tapered off gradually to avoid adrenal insufficiency, a potentially life-threatening complication. The American College of Gastroenterology advises against using steroids for maintenance therapy.
Immunomodulators: Long-Term Immune Control
Immunomodulators (azathioprine, mercaptopurine, cyclosporine, tacrolimus) suppress the immune system to reduce inflammation. They are reserved for cases where aminosalicylates or steroids are ineffective.
- These drugs take months to show results but can reduce the need for steroids.
- Immunomodulators increase the risk of infections, so regular blood tests are essential to monitor function and viral status.
Biologics: Targeting Inflammation Proteins
Biologics (infliximab, adalimumab, golimumab, vedolizumab, ustekinumab, risankizumab, mirikizumab) target specific proteins involved in inflammation. They are used for moderate to severe UC.
- TNF inhibitors block tumor necrosis factor (TNF), a key inflammatory protein.
- Integrin blockers prevent white blood cells from entering the GI tract.
- Interleukin blockers suppress IL-12 and IL-23, other inflammatory signals.
Biologics can increase infection risk and may cause allergic reactions, but they are often effective in controlling symptoms when other drugs fail.
Small Molecules: New Approaches to Immune Modulation
Small molecules (tofacitinib, upadacitinib, ozanimod, etrasimod) are oral medications that suppress the immune system through different pathways than biologics.
- JAK inhibitors (tofacitinib, upadacitinib) block the JAK enzyme, preventing inflammatory signals. The FDA has issued warnings about increased risk of heart events, cancer, and blood clots with these drugs.
- S1P modulators (ozanimod, etrasimod) reduce immune cell movement into the intestines.
These medications offer a convenient oral option but require careful monitoring due to potential side effects.
The Bottom Line
Medication is central to managing ulcerative colitis, aiming to suppress inflammation and reduce symptoms. Treatment options range from aminosalicylates for mild cases to biologics and small molecules for severe disease. Selecting the best approach requires careful consideration of individual health, disease severity, and potential risks. Working closely with a gastroenterologist is essential for long-term management and improved quality of life.
