Medical treatment of UC has two separate goals:
- the induction of remission (making a sick person well), and
- the maintenance of remission (keeping them well and preventing flare-ups).
Surgery is also a treatment option for UC and will be discussed separately. Medication choices can be grouped into four general categories:
- immunomodulators, and
Aminosalicylatesare a group of anti-inflammatory medications. Examples include sulfasalazine, mesalamine, olsalazine, and balsalazide. These are used to get rid of inflammation and keep it gone. They are used in mild to moderate UC. They come in both pill and rectal forms (suppositories and enemas). They 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 forms of mesalamine are used more often if UC is just the end of their colon..
Steroids(prednisone or budesonide) work well to get rid of inflammation. They come in oral, rectal, and intravenous (IV) forms. They can be used in more moderate to severe cases. Some steroids are absorbed into the blood and have a number of side effects. That’s why they are not a good option for long-term use. Side effects include cataracts, osteoporosis (thinning of the bones), mood effects, and increased chance of infections. Others are high blood pressure, high blood sugar and weight gain. Some steroids are less absorbed and work mainly in the colon with less side effects.
Immunomodulators include medications such as 6-mercaptopurine and azathioprine (thiopurines). These are taken in pill form and absorbed into the bloodstream. They work to just keep inflammation gone but are slow to work. They can take up to two to three months to really help. Because of this, these are usually combined with other medications (such as steroids). Typically in those with moderate to severe disease. Frequent blood tests are needed though. That is because these can injure the liver or decrease blood cells. If either happen, they go away after stopping the drug. Other side effects include nausea, rash, inflammation of the pancreas, and, rarely, lymphoma.
Biologic agents are medications given by IV or a shot that are used to treat moderate to severe UC. There are several different types.
- First is the class of anti-TNF therapies. These target an inflammatory protein called “TNF”. They can work for both the 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 called a "hypersensitivity reaction." There are also rare risks of serious infections with these. Lymphoma is another rare risk. But more recent scientific studies say that this may not be from these medications, but instead due to the thiopurine immune drugs (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. By doing this it can decrease 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.
- A third biologic is one that blocks two proteins called interleukins that cause inflammation in the colon. There is just one therapy in this class (ustekinumab (Stelara ®). Again, it has been shown to induce and maintain remission of UC.
Tofacitinib is a newer oral drug (not a biological therapy). It too can induce and maintain remission of UC. Tofacitinib (Xeljanz®) works by blocking an enzyme that is needed to turn on inflammation. This drug can work quickly. However it may increase cholesterol levels. It also may increase the risk of getting the shingles infection (related to chicken pox). This risk can be decreased by getting the shingles vaccine.
The most recent oral drug that’s not a biologic is called ozanimod. Ozanimod (Zeposia ®) works to block the blood cells that cause inflammation from ever leaving the lymph nodes. This has been shown to help in both moderate and severe UC but can decrease the heartrate or cause swelling of the eye. An electrocardiogram (ECG) should be done before starting. Also if you have a history of conditions affecting the eye, such as uveitis, you may not be able to use this drug.
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 drugs are sometimes used in those rare cases of severe UC that don’t respond to anything else. Side effects can include infections and kidney problems. These are only offered at a limited number of Tofacitinib is a newer oral drug (not a biological therapy). It too can induce and maintain remission of UC. Tofacitinib (Xeljanz®) works by blocking an enzyme that is needed to turn on inflammation. This drug can work quickly. However it may increase cholesterol levels. It also may increase the risk of getting the shingles infection (related to chicken pox). This risk can be decreased by getting the shingles vaccine. hospitals and are usually used for a short period of time. If used, the goal is to get you better long enough to get onto other drugs for long-term.
Taking Medication for UC as Prescribed: No matter which medication you and your doctor decide on, it is very important to take it as directed. No medical therapy can work if it is not taken. Missing doses can lead to treatments that may have been avoided if not mentioned to your doctor. Plus uncontrolled inflammation is what causes many of the complications. So by taking your medicine, the chances of these happening are decreased.