Digestive Disorders > IBD > Ulcerative Colitis

How is ulcerative colitis treated?

Dr. med. Andre Sommer

Dr. med. Andre Sommer

Ulcerative colitis is an inflammatory bowel disease. The cause of the inflammation has not yet been fully clarified, so the disease is not yet causally treatable. Ulcerative colitis sufferers experience symptoms throughout their lives, making it a so-called chronic disease.

The main aim of treatment is to contain the inflammation and thus prevent relapses. It is also important to correct a lack of nutrients such as iron.

What drugs are used to treat ulcerative colitis?

Treating physicians decide whether drug therapy for ulcerative colitis is necessary and which therapy makes sense. Because the drugs have a strong effect on the body, they are only available on prescription.

The different classes of active ingredients that are used to treat ulcerative colitis:

  • 5-ASA preparations (aminosalicylates)
  • Glucocorticoide
  • Calcineurin inhibitors
  • TNF antibodies
  • Purine antagonists

The substances work at various points in the immune system. An important mode of action of the agents is that they inhibit the activity of certain messenger substances in the immune system. This way, renewed intestinal inflammation can be prevented. With ulcerative colitis, drugs can be used that only act at the site of inflammation in the intestine (local/topical effect), but also drugs that are distributed throughout the body (systemic effect).

Which drug classes and drugs are there and how are they administered?

Active drug class Drug Dosage form
Aminosalicylate

(5-ASA preparations)

Mesalazine

Rarely: Sulfasalazine, mesalazine (side effects are common)

Tablets, suppositories, foam preparations (as enema)
Glucocorticoide Budesonide, cortisone Suppositories / enemas, infusion (intravenous),

Tablets (oral)

Calcineurin inhibitors Ciclosporin A, tacrolism Tablets (oral), except infusion (intravenous)
TNF antibodies Infliximab (e.g. Remicade®) Self-injection under the skin (subcutaneous), infusion (intravenous)
Purine antagonists Azathioprine Tablets (oral)

Fig. 1. Medicines for ulcerative colitis therapy

How is a relapse handled?

The medications that are used to treat a relapse depend on several factors:

  • the severity
  • the frequency of the relapse
  • the spread of inflammation
  • response to therapy
  • side effects from previous therapies

Which medication you are already taking for maintenance therapy (remission) also plays a role. If this remedy cannot stop the relapse, a step-by-step scheme is used. That means switching from a weaker to more effective (more potent) medication or combination. This is more likely to successfully contain the inflammation. However, this often means that stronger side effects occur.

According to the current guidelines for treatment, the following therapy regimen is recommended:

Indication Medication
Light flare-up 5-ASA preparations locally (topically)
Moderate flare-up 5-ASA preparations locally (topically)

or

5-ASA preparations local (topical) and 5-ASA preparations oral (systemic)

or

5-ASA preparations topical and glucocorticoids (topical)

Strong flare-up Glucocorticoids (systemic)
Severe flare-up and no response to glucocorticoids Immunosuppressants (systemic):

- Ciclosporin A, tacrolism

- Infliximab

- Azathioprine

Fig. 2.: Drug therapy during a relapse

If there is inflammation in the last section of the large intestine, this is so-called proctitis. Here, treatment with 5-ASA can be topical (i.e., directly applied at the affected area). The active substance is applied directly to the inflamed colon area via suppositories or enemas (clysms).

However, if the inflammation has spread further up the colon (left-sided colitis), the inflammation can no longer be reached everywhere. Therefore 5-ASA is additionally administered as tablets or granules. These then migrate through the entire gastrointestinal tract from the mouth, esophagus, and stomach through the small intestine to the large intestine, but only release their active ingredient in the large intestine.

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What does maintenance therapy mean?

One speaks of remission when the person concerned is completely symptom-free. In such a phase there is no inflammation in the intestine. The disease is not cured, but the sufferer has no complaints and can freely go about their everyday life. One tries to maintain this symptom-free state as long as possible. The drug treatment used for this is called maintenance therapy.

To maintain remission, those affected receive 5-ASA preparations in the form of tablets (oral) or as a suppository or enema (rectal). These are the same drugs used in acute relapse. In maintenance therapy, however, the drugs have a lower dosage. If relapses occur while taking 5-ASA supplements, immunosuppressants (azathioprine or infliximab) can be used.

Maintenance therapy should be given for at least two years. Since ulcerative colitis increases the risk of colon cancer depending on the inflammatory activity, it may also make sense to take the medication for longer. This lowers the risk of cancer. But one must be careful with glucocorticoids. Even if they are effective in the acute therapy of a relapse, they should not be used in the long term to maintain remission. Glucocorticoids intervene in the hormonal balance and are associated with strong side effects when used for a long time.

Can there be relapses despite maintenance therapy?

Under certain circumstances, further relapses may also occur while taking medication to maintain the remission. In the event of a severe relapse, drug therapy is adjusted to stop the inflammation as quickly as possible. If a 5-ASA preparation has already been taken as part of maintenance therapy, the dose is increased first.

Therapy with immunosuppressants such as anti-TNF, vedolizumab or with thiopurines is also possible. If immunosuppressive during are already used during relapse prevention, the relapse is treated directly with glucocorticoids.

Can ulcerative colitis be treated surgically?

Some chronic inflammatory bowel diseases, such as Crohn's disease, cannot be cured by surgery. Things are different with ulcerative colitis: The disease can be cured by surgical removal of the large intestine (proctocolectomy). But this is a major intervention: So that the retention and storage of stool (continence) is still possible, an artificial reservoir is formed from part of the small intestine in addition to the removal of the large intestine. This reservoir then catches the stool. Thus, a large part of the entire intestine is affected by the surgical intervention. It should also be borne in mind that the stool will then be significantly more fluid. This is because the main function of the colon is to remove fluid from the stool. If this is not done, the stool has a consistency that is otherwise like diarrhea. For these reasons, surgery for ulcerative colitis is rarely recommended.

However, if the disease becomes acute and life-threatening complications arise, surgery is required. This includes, for example, the rupture of the large intestine (perforation). There are also situations in which surgery can be decided for without acute deterioration (elective surgical indication). This is the case, for example, if severe flare-ups occur frequently. The same applies if the general condition deteriorates or changes in the mucosal cells have already occurred (epithelial dysplasia). Epithelial dysplasia is a precursor to colon cancer.

Can ulcerative colitis also be treated with naturopathy?

The effect has not been scientifically proven for many naturopathic procedures. In this case, the guideline for the treatment of ulcerative colitis therefore advises against the use of naturopathic methods of therapy. However, there are indications of a positive effect for a few therapies. But it is important to use them in addition to the recommended medication (see above). Complementary use in addition to standard therapy is called integrative medicine or complementary use.

  • Individual studies have shown an effect for these naturopathic remedies:
  • Curcumin (yellow root): to maintain remission (plus 5-ASA preparations)
  • Plantago ovate (plantain): to maintain remission (plus 5-ASA preparations)
  • Combination of myrrh, chamomile flower extract and coffee charcoal: to maintain remission (plus 5-ASA preparations)
  • Probiotics (Escherichia coli, Lactobacillus, Bifidobacterium): to maintain remission (plus 5-ASA preparations)
  • Mind and Body Medicine (meditation, mindfulness training, yoga): to improve the quality of life
  • Acupuncture: mild to moderate relapse (plus respective standard relapse therapy)

Which homeopathic remedies are suitable to treat ulcerative colitis?

The effect of homeopathic remedies is very controversial in scientific circles and is rejected in specialist circles. The data on efficacy is poor, so generally no recommendation for homeopathic therapy can be given. Nevertheless, many patients are interested in homeopathy and hope to benefit from taking the globules (homeopathic beads). The homeopathic therapeutic agents used are tailored to the treatment of the symptoms and complaints that occur with ulcerative colitis (diarrhea, abdominal pain, bleeding).

If homeopathic therapy is desired, a doctor or alternative practitioner who is trained in homeopathy should recommend a suitable preparation. However, surveys show that few patients actually benefit from homeopathy and other procedures. In any case, those affected should under no circumstances give up standard therapy.

How important is nutrition in therapy?

Diet plays a major role in the treatment of ulcerative colitis. It has a direct influence on the intestinal flora and thus on the overall intestinal health. It is advisable to find out with a qualified nutritionist which diet is best suited for you individually. In this way symptoms can be reduced and quality of life increases.

Arastéh, K., Baenkler, H. W., Bieber, C., Brandt, R., & Chatterjee, T. T. (2012). Duale Reihe Innere Medizin. Georg Thieme Verlag.

Authors, Collaborators: [Updated S3-Guideline Colitis ulcerosa. German Society for Digestive and Metabolic Diseases (DGVS) - AWMF Registry 021/009]. Z Gastroenterol. 2018;56(9):1087-1169. doi:10.1055/a-0651-8174

Sang L-X, Chang B, Zhang W-L, Wu X-M, Li X-H, Jiang M. Remission induction and maintenance effect of probiotics on ulcerative colitis: a meta-analysis. World J Gastroenterol. 2010;16(15):1908-1915. doi:10.3748/wjg.v16.i15.1908

Dr. med. Andre Sommer

Dr. med. Andre Sommer

I’m André, a medical doctor from Berlin. Together with a team of medical doctors, nutritionists and data scientists we empower people to understand digestive issues with our app Cara.

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