Pancolitis - Treating ulcerative colitis

Treatment for ulcerative colitis depends on how severe the condition is and how often your symptoms flare up.

The main aims of treatment are to:

reduce symptoms, known as inducing remission (a period without symptoms)
maintain remission

This will usually involve taking various types of medication, although surgery may sometimes be an option.

Your treatment will normally be provided by a range of healthcare professionals, including specialist doctors (such as gastroenterologists or surgeons), GPs and specialist nurses.

Your care will often be co-ordinated by your specialist nurse and your care team, and they will usually be your main point of contact if you need help and advice.

Aminosalicylates

Aminosalicylates (ASAs), such as sulphasalazine or mesalazine, are medications that help to reduce inflammation. They are usually the first treatment option for mild or moderate ulcerative colitis.

ASAs can be used as a short-term treatment to treat flare-ups. They can also be taken long term, usually for the rest of your life, to maintain remission.

ASAs can be taken:

orally – by swallowing a tablet or capsule
as a suppository – a capsule that you insert into your rectum (bottom), where it then dissolves
through an enema – where fluid is pumped into your large intestine

How you take ASAs will depend on the severity and extent of your condition.

The side effects of ASAs can include headaches, feeling sick, diarrhoea, abdominal (tummy) pain and a rash.

Corticosteroids

Corticosteroids, such as prednisolone, are a more powerful type of medication used to reduce inflammation. They can be used with or instead of ASAs to treat a flare-up if ASAs alone are not effective.

Like ASAs, steroids can be administered orally, or through a suppository or enema.

However, unlike ASAs, corticosteroids are not used as a long-term treatment to maintain remission because they can cause potentially serious side effects, such as osteoporosis (weakening of the bones) and cataracts (cloudy patches in the lens of the eye) when used for a long time.

Side effects of short-term steroid use can include acne, increased appetite, mood changes (such as becoming more irritable) and mood swings.

Read more about the side effects of corticosteroids.

Immunosuppressants

Immunosuppressants, such as tacrolimus and azathioprine, are medications that reduce the activity of the immune system. They are usually given as tablets to treat mild or moderate flare-ups, or maintain remission if your symptoms haven't responded to other medications.

Immunosuppressants can be very effective in treating ulcerative colitis, but they often take a while to start working (usually between two and three months).

The medicines can make you more vulnerable to infection, so it is important to report any signs of infection, such as fever or sickness, promptly to your GP.

They can also lower the production of red blood cells, making you prone to anaemia. You will need regular blood tests to monitor your blood cell levels and to check for any other problems.

Treating severe flare-ups

While mild or moderate flare-ups can usually be treated at home, more severe flare-ups should be managed in hospital to minimise the risk of dehydration, malnutrition and potentially fatal complications, such as your colon rupturing.

In hospital, you will be given medication and fluids intravenously (directly into a vein). The medication you have will usually be a type of corticosteroid or an immunosuppressant medication called ciclosporin.

If ciclosporin is also unsuitable, you may be given a medication called infliximab.

Ciclosporin

Ciclosporin works in the same way as other immunosuppressant medications (see above) – by reducing the activity of the immune system. However, it is more powerful than the medications used to treat milder cases of ulcerative colitis and starts to work much sooner (normally within a few days).

Ciclosporin is given slowly through a drip in your arm (known as an infusion) and treatment will usually be continuous, for around seven days.

Side effects of intravenous ciclosporin can include:

a tremor (an uncontrollable shaking or trembling of part of the body)
excessive hair growth
fatigue (extreme tiredness)
swollen gums
feeling and being sick
diarrhoea

Ciclosporin can also cause more serious problems such as high blood pressure and reduced kidney and liver function, but you will be monitored regularly during treatment to check for signs of these.

Infliximab

Infliximab is a type of medication that works by targeting a protein called TNF-alpha, which the immune system uses to stimulate inflammation.

Infliximab is given as an infusion over the course of two hours. You will be given further infusions after two weeks, and again after six weeks. Infusions are then given every eight weeks, if treatment is still required.

Common side effects of infliximab can include:

increased risk of infection – report any symptoms of a possible infection, such as coughs, high temperature or sore throat, to your GP
vertigo (the sensation you or the environment around you is moving) and dizziness
an allergy-like reaction, causing breathing difficulties, urticaria (hives) and headaches

In most cases, a reaction to the medication occurs in the first two hours after the infusion has finished. However, some people experience delayed reactions days, or even weeks, after an infusion. If you begin to experience the symptoms listed above after having infliximab, seek immediate medical assistance.

You will be carefully monitored after your first infusion and, if necessary, powerful anti-allergy medication, such as epinephrine, may be used.

Infliximab is not usually suitable for people with a history of tuberculosis (TB) or hepatitis B, because there have been a number of cases where infliximab has "reactivated" dormant infections. The medication is also not recommended for people with a history of heart disease.

Surgery

If you have frequent flare-ups that have a significant effect on your quality of life, or you have a particularly severe flare-up that isn't responding to medication, surgery may be an option.

Surgery for ulcerative colitis involves permanently removing the colon (known as a colectomy).

During the operation, your small intestine will be used to pass waste products out of your body instead of your colon. This can be achieved by creating:

an ileostomy – where the small intestine is diverted out of a hole made in your abdomen. Special bags are placed over this opening, to collect waste materials after the operation
an ileo-anal pouch – where part of the small intestine is used to create an internal pouch that is then connected to your anus, allowing you to pass stools normally

Ileo-anal pouches are increasingly used because an external bag to collect waste products is not required.

As the colon is removed, ulcerative colitis cannot recur after surgery. However, it's important to consider the risks of surgery and the impact of having a permanent ileostomy or ileo-anal pouch.

Read more about ileostomies and ileo-anal pouches.

Acute: Acute means occurring suddenly or over a short period of time.
Antidiarrhoeals: Antidiarrhoeal medicine is used to treat diarrhoea. For example, dicyclomine.
Corticosteroids: Corticosteroid is a naturally occurring hormone produced by the adrenal gland, or a synthetic hormone having similar properties. It is used to reduce inflammation, so reducing swelling and pain.
Enemas: An enema is an injection of fluid into the large intestine / colon to empty the bowel. It can also be used to make the bowels show up more clearly in an X-ray.
Inflammation: Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.
Intravenous: Intravenous (IV) means the injection of blood, drugs or fluids into the bloodstream through a vein.
Remission: Remission is when the symptoms of a condition are reduced (partial remission) or go away completely (complete remission).