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How is ulcerative colitis treated?

A health care provider treats ulcerative colitis with the following:

• medications
• surgery

Which treatment a person needs depends on the severity of the disease and the symptoms. Each person experiences ulcerative colitis differently, so health care providers adjust treatments to improve the person's symptoms and induce, or bring about, remission.

Medications

While no medication cures ulcerative colitis, many can reduce symptoms. The goals of medication therapy are the following:

• inducing and maintaining remission
• improving the person's quality of life

Many people with ulcerative colitis require medication therapy indefinitely, unless they have their colon and rectum surgically removed.

ÐÇ¿Õ´«Ã½ care providers will prescribe the medications that best treat a person's symptoms. These may include the following:

• aminosalicylates
• corticosteroids
• immunomodulators
• biologics, also called anti-TNF therapies
• other medications

Depending on the location of the symptoms in the colon, health care providers may recommend a person take medications by

• enema, which involves flushing liquid medication into the rectum using a special wash bottle. The medication directly treats inflammation of the large intestine.
• rectal foam—a foamy substance the person puts into the rectum like an enema. The medication directly treats inflammation of the large intestine.
• suppository—a solid medication the person inserts into the rectum to dissolve. The intestinal lining absorbs the medication.
• mouth.
• IV.

Aminosalicylates are medications that contain 5-aminosalicyclic acid (5-ASA), which helps control inflammation. ÐÇ¿Õ´«Ã½ care providers typically use aminosalicylates to treat people with mild or moderate symptoms or help people stay in remission. Aminosalicylates can be prescribed as an oral medication or a topical medication—by enema or suppository. Combination therapy—oral and rectal—is most effective, even in people with extensive ulcerative colitis. Aminosalicylates are generally well tolerated.

Aminosalicylates include the following:

• balsalazide
• mesalamine
• olsalazine
• sulfasalazine—a combination of sulfapyridine and 5-ASA

Some of the common side effects of aminosalicylates include the following:

• abdominal pain
• diarrhea
• headaches
• nausea

ÐÇ¿Õ´«Ã½ care providers may order routine blood tests for kidney function, as aminosalicylates can cause a rare allergic reaction in the kidneys.

Corticosteroids, also known as steroids, help reduce the activity of the immune system and decrease inflammation. ÐÇ¿Õ´«Ã½ care providers prescribe corticosteroids for people with more severe symptoms and people who do not respond to aminosalicylates. ÐÇ¿Õ´«Ã½ care providers do not typically prescribe corticosteroids for long-term use.

Corticosteroids are effective in bringing on remission; however, studies have not shown that the medications help maintain long-term remission. Corticosteroids include the following:

• budesonide
• hydrocortisone
• methylprednisone
• prednisone

Side effects of corticosteroids include the following:

• acne
• a higher chance of developing infections
• bone mass loss
• death of bone tissue
• high blood glucose
• high blood pressure
• mood swings
• weight gain

People who take budesonide may have fewer side effects than with other steroids.

Immunomodulators reduce immune system activity, resulting in less inflammation in the colon. These medications can take several weeks to 3 months to start working. Immunomodulators include the following:

• azathioprine
• 6-mercaptopurine, or 6-MP

ÐÇ¿Õ´«Ã½ care providers prescribe these medications for people who do not respond to 5-ASAs. People taking these medications may have the following side effects:

• abnormal liver tests
• feeling tired
• infection
• low white blood cell count, which can lead to a higher chance of infection
• nausea and vomiting
• pancreatitis
• slightly increased chance of lymphoma
• slightly increased chance of nonmelanoma skin cancers

ÐÇ¿Õ´«Ã½ care providers routinely test blood counts and liver function of people taking immunomodulators. People taking these medications should also have yearly skin cancer exams.

People should talk with their health care provider about the risks and benefits of immunomodulators.

µþ¾±´Ç±ô´Ç²µ¾±³¦²õ—including adalimumab, golimumab, infliximab, and vedolizumab—are medications that target a protein made by the immune system called tumor necrosis factor (TNF). These medications decrease inflammation in the large intestine by neutralizing TNF. Anti-TNF therapies work quickly to bring on remission, especially in people who do not respond to other medications. Infliximab and vedolizumab are given through an IV; adalimumab and golimumab are given by injection.

ÐÇ¿Õ´«Ã½ care providers will screen patients for tuberculosis and hepatitis B before starting treatment with anti-TNF medications.

Side effects of anti-TNF medications may include the following:

• a higher chance of developing infections—especially tuberculosis or fungal infection
• skin cancer—melanoma
• psoriasis

Other medications to treat symptoms or complications may include the following:

• acetaminophen for mild pain. People with ulcerative colitis should avoid using ibuprofen, naproxen, and aspirin since these medications can make symptoms worse.
• antibiotics to prevent or treat infections.
• loperamide to help slow or stop diarrhea. In most cases, people only take this medication for short periods of time since it can increase the chance of developing megacolon. People should check with a health care provider before taking loperamide, because those with significantly active ulcerative colitis should not take this medication.6
• cyclosporine—health care providers prescribe this medication only for people with severe ulcerative colitis because of the side effects. People should talk with their health care provider about the risks and benefits of cyclosporine.

Surgery

Some people will need surgery to treat their ulcerative colitis when they have:

• colon cancer;
• dysplasia, or precancerous cells in the colon;
• complications that are life threatening, such as megacolon or bleeding;
• no improvement in symptoms or condition despite treatment;
• continued dependency on steroids;
• and/or side effects from medications that threaten their health.

Removal of the entire colon, including the rectum, "cures" ulcerative colitis. A surgeon performs the procedure at a hospital. A surgeon can perform two different types of surgery to remove a patient's colon and treat ulcerative colitis:

• proctocolectomy and ileostomy, or
• proctocolectomy and ileoanal reservoir.

Full recovery from both operations may take 4 to 6 weeks.

Proctocolectomy and ileostomy. A proctocolectomy is surgery to remove a patient's entire colon and rectum. An ileostomy is a stoma, or opening in the abdomen, that a surgeon creates from a part of the ileum—the last section of the small intestine. The surgeon brings the end of the ileum through an opening in the patient's abdomen and attaches it to the skin, creating an opening outside of the patient's body. The stoma most often is located in the lower part of the patient's abdomen, just below the beltline.

A removable external collection pouch, called an ostomy pouch or ostomy appliance, connects to the stoma and collects intestinal contents outside the patient's body. Intestinal contents pass through the stoma instead of passing through the anus. The stoma has no muscle, so it cannot control the flow of intestinal contents, and the flow occurs whenever peristalsis occurs. Peristalsis is the movement of the organ walls that propels food and liquid through the GI tract.

People who have this type of surgery will have the ileostomy for the rest of their lives.

Proctocolectomy and ileoanal reservoir. An ileoanal reservior is an internal pouch made from the patient's ileum. This surgery is a common alternative to an ileostomy and does not have a permanent stoma. Ileoanal reservoir is also known as a J-pouch, a pelvic pouch, or an ileoanal pouch anastamosis. The ileoanal reservior connects the ileum to the anus. The surgeon preserves the outer muscles of the patient's rectum during the proctocolectomy. Next, the surgeon creates the ileal pouch and attaches it to the end of the rectum. Waste is stored in the pouch and passes through the anus.

After surgery, bowel movements may be more frequent and watery than before the procedure. People may have fecal incontinence—the accidental passing of solid or liquid stool or mucus from the rectum. Medications can be used to control pouch function. Women may be infertile following the surgery.

Many people develop pouchitis in the ileoanal reservoir. Pouchitis is an irritation or inflammation of the lining of the ileoanal reservoir. A health care provider treats pouchitis with antibiotics. Rarely, pouchitis can become chronic and require long-term antibiotics or other medications.

The surgeon will recommend one of the operations based on a person's symptoms, severity of disease, expectations, age, and lifestyle. Before making a decision, the person should get as much information as possible by talking with:

• health care providers;
• enterostomal therapists, nurses who work with colon-surgery patients;
• or people who have had one of the surgeries.

Patient-advocacy organizations can provide information about support groups and other resources.