A Pharmacist Explains the Types and Other Options

Ulcerative colitis medications help control the symptoms of ulcerative colitis (UC) and prevent flare-ups or relapses.

UC is a chronic inflammatory bowel disease. It’s an autoimmune condition, meaning the body’s immune system attacks healthy parts of the body.

A medication plan and lifestyle modifications tailored to you may help you minimize symptoms and prevent relapses and other complications.

Your healthcare provider will work with you to find the best medication. Regular communication with them throughout your treatment is key.

What Is the Best Medication for Ulcerative Colitis?

The best medicine for ulcerative colitis depends on several factors, such as the severity of the disease and its location.

Severity is determined by how often you have bowel movements and whether there’s blood in the stool. People with mild to moderate UC have less than six bowel movements per day, with minimal rectal bleeding.

Moderate to severe UC means you have more than six bowel movements daily, plus rectal bleeding. Moderate to severe UC also includes signs of body-wide effects (like fever or markers of inflammation).

There’s no cure for UC yet, apart from surgery to remove the colon. UC may not go away with medications, but they can help manage it.

UC can also go into remission, meaning the symptoms stop for a while. However, symptoms may reappear.

The following includes medications typically used for UC.

Aminosalicylates (5-ASA)

• How they work: Anti-inflammatory effects in the colon.
• 5-ASA examples: Asacol HD, Canasa, Pentasa (mesalamine), Giazo, Colazal (balsalazide), and Azulfidine (sulfasalazine).
• What they are used for: First choice treatment for mild to moderate UC. They are used for maintenance therapy (to prevent flares). Aminosalicylates can be taken by mouth or inserted into the rectum, depending on where inflammation is located. Be sure to follow your healthcare provider’s directions on how to take your medication.
• Side effects: Headache, nausea, diarrhea, kidney inflammation; sulfasalazine (but not other 5-ASAs) may also cause hemolytic anemia or hepatitis.
• Precautions: Due to possible kidney toxicity, your kidney function should be monitored regularly.

Corticosteroids

• How they work: Broad suppression of your body’s immune system.
• Examples: Omnipred (prednisolone), Deltasone (prednisone), Cortiment MMX (budesonide), Medrol (methylprednisolone), and Solu-Cortef (hydrocortisone).
• What they are used for: First choice for moderate to severe flare-ups. This is a second choice for mild to moderate UC that doesn’t respond to 5-ASA. Corticosteroids (steroids) are typically taken by mouth but can also be injected into a vein (intravenously or IV) in a hospital setting. Keep in mind that steroids should only be used short-term due to side effects.
• Side effects: Osteoporosis, weight gain, adrenal suppression, insomnia, mood changes, glaucoma, cataracts, infections, blood sugar disorders, peptic ulcers, heart problems, and hip fractures.
• Precautions: Some side effects are not reversible. If you take a corticosteroid for longer than three months, you’ll need extra lab tests, including an eye exam and bone density test.

Immunomodulators

• How they work: Suppress your immune system to reduce inflammation.
• Examples: Imuran (azathioprine) and Purixan (mercaptopurine).
• What they are used for: Long-term management of mild to moderate UC. It can also reduce steroid dependence (allowing for a lower dose of steroids). Of note, immunomodulators can take up to 12 weeks to work, so steroids are typically given with them at the beginning of treatment.
• Side effects: Nausea, vomiting, hepatitis, pancreatitis, infections, cancer, fever, rash, muscle pain.
• Precautions: Due to side effects, cancer screenings and frequent checks of liver function and blood count are recommended.

Biologics

• How they work: Target specific proteins involved in inflammation.
• Examples: Remicade (infliximab), Humira (adalimumab), Simponi (golimumab), Entyvio (vedolizumab).
• What they are used for: First choice for severe disease; used for moderate to severe UC when other treatments fail. Must be injected IV or into the skin (subcutaneously or SQ).
• Side effects: Skin reactions at the site of injection, infections, reactivation of tuberculosis or hepatitis B, cancer, lupus, psoriasis, eczema.
• Precautions: Biologics may cause the body to develop antibodies to the medicine, making it ineffective. Before starting treatment, it’s important to rule out tuberculosis or hepatitis B infections.

Targeted Synthetic Small Molecules

• How they work: Target specific pathways in the immune system.
• Examples: Xeljanz (tofacitinib).
• What they are used for: Moderate to severe UC when biologics don’t work.
• Side effects: Infections, anemia, hepatitis, high cholesterol, cancer, shingles, gastrointestinal rupture, pulmonary embolism (blood clot in the lungs).
• Precautions: Stick to low doses if you are at risk of blood clots.

Surgery for Ulcerative Colitis

Biologics have been a game-changer for management, but up to 15% of people with UC may still need surgery. However, some people may not be able to manage UC with medications alone.

Surgery may be needed when UC is not able to be controlled with medications and lifestyle modifications. It is also used for people who have serious complications of UC like the following:

• Excessive hemorrhage
• Cancer
• Toxic megacolon (the colon inflates and loses blood flow, resulting in possible tissue death)

Types of surgery for UC include the following:

• Colectomy, the removal of part or all of the colon. A surgeon can perform this surgery either through a larger incision in the stomach or laparoscopically by using smaller openings.
• Ileostomy, where an opening is made in the stomach wall to allow waste to leave the body through the small intestine instead of the anus. The waste is collected outside the body in a pouch or bag.
• Ileorectal anastomosis, a reconstructive surgery after colon removal.

Other Options for Ulcerative Colitis

Several other therapies have been studied for UC, including the following:

• Acupuncture: Limited clinical trials have studied acupuncture, a form of traditional Chinese medicine that uses needles in the skin at specific points in the body, for UC. It’s been shown to be as effective as some medications for UC, but more data is needed to know for sure.
• Exercise: Moderate-intensity exercise has many benefits for people with UC. These include reducing fatigue and gastrointestinal symptoms, improving mental health, and boosting the body’s immune response. High-intensity exercise may also be appropriate, but discuss this with your healthcare provider for optimal safety.
• Food and nutrition: Diet may play a role in UC management. The Mediterranean diet, high in fruits, veggies, and whole grains, has antioxidant effects that can reduce inflammation. Diets that exclude red meat, sugar, and processed foods have also been suggested. The theory behind this is that removing these foods can improve the bacteria in your gut. However, more research is needed to understand their effectiveness.
• Medical foods: Medical foods are taken by mouth for specific medical conditions under a healthcare provider’s supervision. One such product, EnteraGam, contains serum-derived immunoglobulin. It may play a role in UC that doesn’t respond to other treatments. Case reports showed that EnteraGam caused UC to go into remission, though more data is needed.
• Supplements: Having UC increases the likelihood of low levels of some nutrients (deficiencies). If you have UC, talk to your healthcare provider about supplementing with micronutrients that the colon may not absorb. These can include iron, calcium, and vitamin D, which are crucial for body function. Other supplements that might help include anti-inflammatory curcumin and probiotics, which help regulate the gut.
• Mind-body medicine: The gut-brain connection theory states that improving mental health can improve the function of the digestive system. In this vein, lifestyle interventions like relaxation exercises, mindfulness strategies, meditation, hypnotherapy, and yoga can improve stress levels and quality of life in people with UC.
• Vagus nerve stimulation: Researchers are beginning to study the effects of a vagus nerve stimulator (VNS), approved for epilepsy and depression, on UC. UC is associated with dysfunction in the vagus nerve, which sends messages to the digestive tract. More study is needed.

Symptoms

UC is characterized by inflammation and ulcers (sores) in the rectum’s lining (proctitis). It may also involve the colon (large intestine), which is called colitis. Common symptoms of UC include the following:

• Diarrhea
• Blood in the stool (poop)
• Stomach pain
• Malnutrition
• Fatigue

Sometimes, UC can affect the skin, joints, eyes, liver, or gallbladder. These are called extra-intestinal manifestations because they occur outside the gastrointestinal tract.

If it’s not controlled, UC can severely disrupt daily life. It can also cause complications such as:

• Infections
• Hospitalizations
• Hemorrhage (excessive bleeding)
• Perforation (hole in the intestine)
• Toxic megacolon, which is a medical emergency
• Colorectal cancer

When to Contact Your Healthcare Provider

If you have been diagnosed with UC, watch for flares or concerning symptoms. Contact your healthcare provider if your medications don’t seem to be working or if your symptoms worsen.

Seek emergency medical help right away if you experience any of the following:

• Dehydration (excessive thirst, headache, fatigue, dark urine)
• Bloody diarrhea
• Signs of a ruptured colon, such as sudden stomach pain or fever

Summary

Medications for UC are used to help control symptoms and prevent flares and complications.

Several medication options are available.

Along with medications, alternative treatments that can help manage UC include acupuncture, exercise, nutrition, dietary supplements, and mental health strategies.

If these don’t work, or you have serious complications, you may want to consider discussing surgical options with your healthcare provider.