Part of the treatment of ulcerative colitis is to avoid raw vegetables and fruits (one of the few diseases) as the fiber can be enough mechanical trauma to perpetuate or worsen the symptoms of ulcerative colitis. Notably some patients improve on a milk free diet.
A) Mild to moderate disease
The physician will likely order some mild anti diarrhea drugs. However, this has to be carefully monitored as this would be the wrong thing to order in a patient who is shortly before developing toxic colitis. If the ulcerative colitis is only on the left side (rectum, sigmoid and ascending colon), then corticosteroid enemas for a period of time would be useful until the flare-up is under control.
Mesalamine or 5-amino-salicylic acid (brand names: Rowasa, Asacol, Mesasal, Pentasa, Quintasa and Salofalk) are all useful as either tablets by mouth or given by enema. In essence, this medication tends to get the inflammation under control and helps to tone down the symptoms. More extensive disease may respond to Sulfosalazine (brand names: Salazopyrin, Azulfidine), but in men sperm counts can be affected and other side-effects such as bone marrow toxicity have to be monitored with blood tests. However, if this medication helps to get the disease under control, then long-term lower maintenance would likely be useful.
B) Moderately severe disease
It usually requires oral corticosteroid treatment to control ulcerative colitis of this severity. 40 to 60 mg of oral prednisone is usually required for about 1 or 2 weeks. Then the physician will gradually reduce the dose of prednisone and attempt to switch over to Sulfosalazine as a maintenance.
C) Severe disease
When a person with ulcerative colitis has more than 10 bloody bowel movements per day and this is coupled with abdominal pain, a high temperature and a fast heart beat, the physician will likely eventually decide to hospitalize this patient and get a referral to a gastroenterologist. The amount of blood loss is a danger to the cardiovascular system and also undermines the immune system significantly. High dosages of corticosteroids or ACTH hormone are usually given intravenously. There may be a place of medications that modulate the immune system such as azathioprine(Imuran) or mercaptopurine (brand name: Purinethol). These medications are known to suppress cytotoxic T lymphocytes, which is known to ultimately lead to a response in ulcerative colitis and Crohn’s disease (see Ref.12).
Another such medications is cyclosporine, which can lead to an 80% response rate.
After another 6 months of oral cyclosporine and a switch to azathioprine or mercaptopurine maintenance long term remissions of 50 to 60% in these severe cases can be achieved (Ref. 13). Cases that do not respond have to be carefully monitored in an ICU setting and possible urgent surgery to control the bleeding situation may have to be considered as mentioned under “complications” under the “symptom” heading. Even if these patients who have a more severe form of ulcerative colitis recover and stabilize, a higher percentage of them will likely need an elective total colectomy, because they have more invasive disease with a higher colon cancer rate. Unfortunately at the present time there is no gentler therapy.
Future more specific anti-inflammatory medication
Lately there are some specific anti-inflammatory treatment modalities that have been developed. The newest classes that have been tested in Crohn’s and ulcerative colitis are the human cytokines (interleukin-11) and the anti-cytokine antibodies (anti-tumor necrosis factor or anti-TNF). Ref. 22-25 deal with interleukin-11. Ref. 26 describes among other medications the use of infliximab, a chimeric antibody targeting the anti-TNF, which has done very well in preliminary clinical trials and early postmarketing experience. However, additional clinical trials are needed to show long-term safety and adverse effects of the medication.
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