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Medical Author:

Benjamin Wedro, MD, FACEP, FAAEM

Benjamin Wedro, MD, FACEP, FAAEM

Dr. Ben Wedro practices emergency medicine at Gundersen Clinic, a regional trauma center in La Crosse, Wisconsin. His background includes undergraduate and medical studies at the University of Alberta, a Family Practice internship at Queen's University in Kingston, Ontario and residency training in Emergency Medicine at the University of Oklahoma Health Sciences Center.

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Medical Editor:

Melissa Conrad Stöppler, MD, Chief Medical Editor

Melissa Conrad Stöppler, MD, Chief Medical Editor

Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

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Medical Editor:

Bhupinder Anand, MD

Medications that are used in the treatment of ulcerative colitis may divided into two groups, anti-inflammatory and immune suppressive agents. The decision as to which medication regimen should be used will depend upon the severity of the ulcerative colitis. Physicians and patients need to discuss the benefits and risks of recommended treatments.

If the patient has mild or moderate colitis, the first line of treatment is the use of 5-ASA agents-a combination of two drugs sulfonamide (sulfapyridine) and salicylate that helps to control the inflammation. Sulfasalazine (Azulfidine) is the most commonly used of these drugs. Sulfasalazine can be used for as long as needed and can be given along with other drugs. If the patient does not do well on sulfasalazine, they may respond to the newer 5-ASA agents. The side effects of 5-ASA preparations include nausea, vomiting, heartburn, diarrhea, and headache.

Drug therapy for active inflammatory bowel disease includes the following:

• Mesalamine-derivatives (Asacol, Pentasa): These are used for Crohn's colitis and ulcerative colitis.
• Antibiotics: Clotrimazole (Lotrimin) and ciprofloxacin (Cipro, Ciloxan) are prescribed for Crohn's disease of the rectum and anus.
• Predigested (elemental or polymeric) diet for small bowel Crohn's disease

If the patient has severe colitis or does not respond to mesalamine preparations, they may be treated with corticosteroids. Prednisone (Deltasone, Orasone, Prednicen-M, Liquid Prep), methylprednisolone (Medrol, Depo-Medrol), budesonide (Entocort EC) and golimumab (Simponi) are used to reduce inflammation. These drugs are taken during a flare-up, but are not used for maintenance when the ulcerative colitis is in remission. Corticosteroids can be taken by mouth, IV infusion, through an enema, or as a suppository, depending upon the location and severity of the inflammation.

Long term use of corticosteroids (may cause side effects including weight gain, acne, facial hair, high blood pressure, mood swings, and increased risk of infection.

A doctor will monitor the patient closely while taking these drugs. The idea is to take corticosteroids only for flare-ups for a short period of time. They do not stop the condition from coming back.

If the patient responds only partially to these treatments or have early relapse, the doctor may consider aggressive therapy. Aggressive therapy may include the following steps:

• Hospital admission
• IV steroids instead of oral steroids
• Increasing the steroid dose
• Use of antibiotics (imidazole or ciprofloxacin or both) for Crohn's disease of the rectum and anus

Suppressing the immune system may help to control the symptoms of ulcerative colitis in patients who have failed first line drug treatment or whose disease is advanced. Medications use for this purpose include:

• Azathioprine (Azasan, Imuran) and mercaptopurine (Purinethol)
• Cyclosporine (Gengraf, Neoral, Sandimmune
• Infliximab (Remicade)
• Adalimumab (Humira)

These medications have significant side effects and need close monitoring. The decision to use them as part of the treatment regimen often requires long discussion between patient and doctor.

If these aggressive measures do not work, surgery may be an option to remove the colon.

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