Medical Therapy of Ulcerative Colitis

Mild

• Rectal mesalamine or glucocorticoids as suppository or enema

Mild- moderate

• Oral 5-ASA: many formulations (sulfasalazine, mesalamine, olsalazine, balsalazide) depending on disease location. Used for induction & maintenance of remission. Complications: pancreatitis, abd pain, diarrhea.

• MMX-budesonide: PO budesonide released throughout colon for flare. 1st-pass metab ↓ systemic steroid adverse effects of steroid.

Moderate- severe

• PO prednisone: 40–60 mg w/ taper over several wks to induce remission

• AZA/6-MP: 0.5–1 mg/kg and uptitrate over several wks for maintenance

• Complications: BM suppression, lymphoma, pancreatitis, hepatitis

• ✓ TPMT levels prior to dosing to ↓ risk of generation of toxic metabs.

• In selected cases, add allopurinol to boost activity in non-responders.

• Anti-TNF: ↑ remission rate when AZA combined w/ IFX (Gastro 2014;146:392)

Severe or refractory disease

(Lancet 2017; 389:1218; NEJM 2016; 374:1754 & 2017; 76:1723; JAMA 2019; 321:156)

• IV steroids: 100 mg hydrocort q8h or 16–20 mg methylpred q8h to induce remission w/ plan to taper & switch to non-steroid maintenance.

• Cyclosporine: for severe flares refractory to steroids, 2–4 mg/kg infusion × 7 d w/ goal to Δ to maintenance medication (eg, AZA/6-MP)

• Anti-TNF (infliximab, adalimumab & golimumab): for steroid-refractory flares or to maintain remission. Complic: reactivation of TB (✓ PPD prior to Rx) or viral hepatitis; small ↑ risk NHL; lupus-like rxn, psoriasis, MS, CHF.

• Alternative agents: vedolizumab (α4β7 integrin inhibitor); tofacitinib (JAK inhibitor); ustekinumab (IL-12/23 inhibitor); ozanimod (sphinosine-1- phosphate receptor agonist)

• Investigational: fecal microbiota transplant; etrolizumab (α4β7 inhibitor)