Treatment of Ulcerative colitis

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Medicines cannot cure ulcerative colitis but they can help to control symptoms and prevent complications. Treatment is usually considered in two phases: controlling an acute attack and then maintaining remission (control) of symptoms.

In an acute attack, when the condition is said to be active, the treatment aims are to control the inflammation, reduce symptoms, prevent complications and replace any lost fluids and nutrients.

Three types of medicine are used for treating an acute attack and for maintaining remission:

Aminosalicylates (balsalazide, mesalazine, olsalazine, sulfasalazine)
Corticosteroids (budesonide, hydrocortisone, prednisolone).
Immunosuppressants (azathioprine, ciclosporin, mercaptopurine)

Other medicines which may be used include:

Laxatives and antidiarrhoeals
Nutritional support

You will receive different combinations of treatment, depending on the stage and severity of the condition, the area(s) of the bowel affected and how you respond to treatment.

Treatment of mild to moderate ulcerative colitis affecting the rectum and distal colitis usually begins with a rectal preparation (applied into the back passage) of either a corticosteroid or aminosalicylate.

Enemas or suppositories or rectal foam may be used, depending on the area of bowel affected and what type will work best for you. The advantages of rectal treatments are that the medicines are delivered directly to where they are needed and there is a reduced risk of side effects.

If symptoms do not improve enough, a course of oral (taken by mouth) corticosteroid treatment e.g. prednisolone for four to eight weeks or an oral aminosalicylate (e.g. mesalazine) may be given. This may be in addition to rectal treatment you are already receiving.

Your GP may refer you to a gastroenterologist (specialist in digestive system diseases) to assess the severity of your condition and to start the most appropriate treatment. Your GP may continue your care when it is safe and practical to do so, whilst you remain also under the care of the specialist. If you have a severe attack which is difficult to control, you may need to be admitted to hospital for treatment with corticosteroid injections, fluid replacement and sometimes intravenous feeding (by a drip) and antibiotics.

Aminosalicylates (e.g. balsalazide, mesalazine, olsalazine, sulfasalazine) are effective in treating active ulcerative colitis and for maintenance of remission. These may be given by the rectal and/or oral route. They can provide long-term relief from the symptoms of ulcerative colitis. Balsalazide, mesalazine and olsalazine have reportedly fewer side effects compared to sulfasalazine but all of these medicines are equally effective for the treatment of this condition.

Corticosteroids (steroids) (e.g. budesonide, hydrocortisone and prednisolone) are used to treat acute, mild to moderate ulcerative colitis. They are available as enemas, suppositories or rectal foam. Steroid tablets or capsules (e.g. prednisolone or budesonide) may be needed when other treatments do not work. Steroids are not suitable for maintenance treatment because their long- term use is associated with a higher risk of side effects. There is less risk of serious side effects with rectal corticosteroids as they are not absorbed into the bloodstream in sufficient quantities.

Immunosuppressants When the condition is difficult to control or it is difficult to reduce your oral steroid dose without relapse, an immunosuppressant such as azathioprine or mercaptopurine is used. They may be used in addition to an aminosalicylate for maintenance treatment and can take several weeks to become fully effective. Ciclosporin is used in some specialist centres to treat acute, severe attacks of ulcerative colitis that have not responded to intravenous corticosteroids. These are all very potent (strong) medicines and though effective, can have serious side effects so you will need regular blood tests and check ups whilst taking these to monitor your general health. You can discuss this further with your GP, pharmacist or NHS Direct on 0845 4647.

Laxatives And Antidiarrhoeals Bulk forming laxatives (e.g. ispaghula husk) are sometimes needed to help you pass stools if you have colitis affecting the rectum (back passage) only. Anti-diarrhoeal medicines (e.g. loperamide or codeine) are sometimes needed to control diarrhoea occurring during remission (symptom controlled periods). These must only be taken under the direction of a doctor as they may mask signs of deterioration. Although uncommon, this could include sudden bowel dilation or rupture (tearing or splitting.

Nutritional Support You may need dietary advice and support, particularly during or just after an acute phase of the condition when you may not have been eating well or have poor absorption and/or increased loss of nutrients due to diarrhoea and fluid loss. Limited dietary supplements are available, such as special foods that can be taken as a drink or sometimes frozen, added to soups etc. It is best if you obtain advice from a dietician to discuss your diet and the suitability of these supplements. They can be obtained on a prescription from your doctor or bought from your pharmacy (chemist) but they are expensive if you require regular, large quantities. There is no clear evidence that diet has any effect on the treatment of ulcerative colitis. It is however sensible to avoid foods that you appear to be sensitive to e.g. lactose in milk.

Complementary Treatments Boswellia and chamomile herbal remedies and Chinese herbal medicines have been used to treat ulcerative colitis. There is little evidence to prove how these complementary medicines work or how safe or effective many of them are. Certain herbs and preparations contain ingredients that can be harmful if not used with care or if not obtained from reputable sources.

Dietary supplements, which have been used in the treatment of ulcerative colitis include fish oils, glutamine and folic acid. There is not enough evidence to prove how these supplements work or how safe or effective they are.

Before using any complementary medicine for ulcerative colitis, you should talk to your GP or pharmacist (chemist). You can also phone NHS Direct on 0845 4647.

Rest and Lifestyle Rest is important during an attack to allow healing to take place. It is also sensible to avoid stressful situations, which can make inflammation worse.

Surgery If your ulcerative colitis symptoms are poorly controlled with medication and you have frequent flare-ups and you remain in poor health you may be referred for surgery. Also if you have a life- threatening flare-up with a perforation or uncontrollable bleeding, surgery will be necessary. Surgery will usually involve removing the affected colon (ileostomy). See the section on Ileostomy for further information.