Ulcerative colitis is an inflammatory bowel disease. It causes inflammation and ulcers in the inner lining of the large intestine (colon). Ulcerative colitis is a chronic condition. The goal of treatment is to reduce the inflammation that causes symptoms in order to prevent flare-ups and maintain longer periods of remission.
Treatment options for ulcerative colitis usually include either medication or surgery, as well as a focus on diet and nutrition. Because the symptoms of ulcerative colitis vary from person to person there is no single treatment that works for everyone.
Medications for ulcerative colitis
Medication for ulcerative colitis is usually prescribed to either induce or maintain remission. There are several types of medication that can be used to treat ulcerative colitis. The type you take will depend on the severity and location of your inflammation.
Medication for ulcerative colitis falls into four main categories:
Aminosalicylates contain 5-aminosalicylic acid (5-ASA), which helps control inflammation in the intestine. They include sulfasalazine, mesalamine, and balsalazide. 5-ASA is normally the first step in the treatment of ulcerative colitis. Aminosalicylates can be administered orally, as an enema, or in a suppository, and typically take four to six weeks to work.
Corticosteroids reduce inflammation and include hydrocortisone, prednisolone, and budesonide. They are usually used in the case of moderate or severe ulcerative colitis or in those who don’t respond to 5-ASA medication. Due to the side effects, corticosteroids are typically used on a short-term basis.
Immunomodulators reduce inflammation by suppressing the immune system response that initiates the inflammation process. These include azathioprine, mercaptopurine, cyclosporine, and tofacitinib. Immunomodulators are administered orally and can take up to six months to have an effect.
Biologics are a newer class of drugs used to treat ulcerative colitis. Biologics target specific proteins of the immune system and include infliximab, adalimumab, golimumab, _and _vedolizumab. They can be given through intravenous infusion or injections.
Treating active ulcerative colitis
The treatment goal for those with active ulcerative colitis symptoms is to induce remission. The type of medication your physician will prescribe you will depend on the severity and location of your inflammation.
The following table gives an overview of medication used for those with active ulcerative colitis:
|Severity of symptoms||Medication|
|Mild to moderate||5-ASA (topical)
5-ASA (topical) and 5-ASA (oral)
5-ASA (topical) and glucocorticoids (topical or oral)
|Moderate to severe (or large area of colon affected)||Glucocorticoids (oral)
|Severe and no response to oral glucocorticoids||Glucocorticoids (intravenous)
Fig. 2. Medication for active ulcerative colitis.
Whether the medication prescribed for you is topical or oral depends on the location of the inflammation. If there is inflammation in the last section of the large intestine (known as proctitis) treatment with 5-ASA can be topical via suppositories or enemas.
If the inflammation has spread further up the colon (proctosigmoiditis) 5-ASA is additionally administered orally. The medication then passes through the entire gastrointestinal tract to the large intestine.
Maintenance therapy for ulcerative colitis
Once remission has been achieved maintenance therapy is typically started to prevent future relapses. Maintenance therapies are medications that are appropriate for long-term use. The choice of maintenance therapy depends on the medication taken to induce remission.
Some medications, such as 5-ASA and immunomodulators, are used for both induction and maintenance of remission. In maintenance therapy, however, the medication will be prescribed at a lower dosage. While glucocorticoids may be used for inducing remission, they are not effective or suitable for maintaining remission.
Can there be ulcerative colitis flare-ups despite maintenance therapy?
Medications and lifestyle changes can help reduce the intensity and frequency of ulcerative colitis flare-ups, but not stop them completely.
For patients who initially respond to therapy but then relapse, options include optimizing the drug dose, switching to an alternative medication in the same drug class, or switching to a medication from a different drug class.
Surgery for ulcerative colitis
If medications or lifestyle changes don’t work, or your ulcerative colitis is severe, you may need surgery. Surgery may also be necessary in the event of severe bleeding or if there is an increased risk of cancer.
Surgery may be performed to remove your colon (colectomy) or your colon and rectum (proctocolectomy).
In most cases a procedure called ileal pouch anal anastomosis will be performed. Your surgeon will construct a pouch from the end of your small intestine. The pouch is then attached directly to your anus, allowing you to expel waste relatively normally. This procedure eliminates the need to wear a bag to collect stool.
If it is not possible to perform this procedure, your surgeon can also create a permanent opening in your abdomen (ileal stoma) through which stool is passed for collection in an attached bag.
Ulcerative colitis diet
There is no specific type of diet that has been proven to relieve symptoms in people with ulcerative colitis. However, many individuals with ulcerative colitis find that modifying their diet can help them manage their symptoms and lengthen the amount of time between flare-ups.
Some people find that particular foods make symptoms worse. It is important to identify and limit any foods that lead to worsening of your symptoms. Keeping a food journal may help you track how your diet relates to your symptoms. You could also try a tracking app. (We produce a tracking app called Cara Care that can be used for this purpose.)
Complementary and alternative medicine
Some studies have shown that complementary and alternative medicine can help relieve symptoms of ulcerative colitis and generally contribute to a better quality of life. However the benefits of many therapies have not been scientifically proven and more research is required on the role of complementary medicine in ulcerative colitis.
Some commonly used therapies include:
- Herbal and nutritional supplements (chamomile, fish oil)
- Probiotics (Escherichia coli, Lactobacillus, Bifidobacterium)
- Turmeric (curcumin)
- Mind and body medicine (meditation, mindfulness training, yoga)
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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