Ulcerative colitis (UC) treatment depends on the extent of the disease (ie. just in the rectum (proctitis), the left side of the colon, or involving the entire colon (pan colitis) as well as the severity of the disease.
For mild to moderate disease the best medications belong to a class called 5-aminosalicylic acid (5-ASA) agents. Most patients have mild to moderate disease and can be effectively managed with appropriate doses of 5-ASA drugs which are very safe. These may be with a sulphur component (salazopyrin) or without (mesalazine). Mesalazine comes in a range of products with different delivery sytems to get the bowel to the colon (Mesalamine*, Salofalk, Mezavant, Colazide). Some are tablets and some are granules. These drugs are very good if given in sufficient dose (about 4g per day for mesalazine and at least 6g per day for salazopyrin) to get patients well (into remission) and are also very good or keeping people well and often a lower dose (about 2g per day) is needed then.
For disease that is worst in the lower part of the colon and rectum, the most efective treatment is mesalazine given as a suppository (a tablet placed into the rectum) or an enema (a liquid or foam spuirted into the rectum and lower colon). Suppositories or enemas are very good at getting people into remission and many patients can then stay well just on an oral form of the same drugs or might need an occasional enema or suppository to stay well.
For disease that is more severe or doesn't respond to 5-ASA drugs within 2 weeks, corticosteroids such as prednisolone is usually needed. This is a very effective drug for the inflammation but has significant side effects especially if used long term. This is normally added to the 5-ASA drug. Corticosteroids can also be given as a suppository or emema.
If the disease is severe and not improving with prednisolone, often an admission to hospital for intravenous corticosteroids is required and in very severe cases, other treaments such as cyclopsporin or infliximab may be needed.
Once the initial or acute episode comes into remission, we usually continue the 5-ASA agent. If there is a frequent need for prednisolone or a hospital admission is required to treat a severe flare, then an immunosuppressant agent such as azathioprine (Imuran) or 6-mercaptopurine (Puri-Nethol) is then started to try to keep the patient in remission and avoid the need for more prednisolone.
If these drugs are not working, then many IBD centres around Australia run clinical trials of newer agents trying to gain registration for use in UC. Often contacted Crohn's and Colitis Australia (www.crohnsandcolitis.com.au) is a good place to start to find out if there are trials in your area.
In some patients surgery is needed. This is removal of the whole colon either because of very severe disease at risk of colon rupture, ongoing difficult to control disease despite large doses of medications or long standing UC with some changes in the bowel that increase the risk of developing bowel cancer. Over the lifetime of the illness, this is required in between 15-25% of patients.
* the product name has been edited to the drug class.
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