Ulcerative colitis affects about 500,000 persons in the United States and accounts for more than 30,000 hospitalizations and 1 million workdays lost each year.1 The exacerbations and remissions that characterize the clinical course of the disease can make its management particularly challenging. What is the optimal approach to treatment? And which agents are most effective for maintenance therapy?
Recently published practice guidelines for the management of ulcerative colitis in adults provide answers to these and other key questions. The highlights of these guidelines, which were developed under the auspices of the American College of Gastroenterology, are summarized here.1
Stool examination, sigmoidoscopy or colonoscopy, and biopsy are indicated to confirm the presence of colitis and to rule out infectious causes in patients who have bloody diarrhea, rectal urgency, or tenesmus. Order microbiologic studies for bacteria, parasites, and amebas; include assays for Escherichia coli 0157:H7 and Clostridium difficile, particularly in patients who have recently been hospitalized or treated with antibiotics. Characteristic endoscopic and histological findings in the absence of evidence of an infectious cause suggest ulcerative colitis. The mucosal changes characteristic of ulcerative colitis, as detected by proctosigmoidoscopy or colonoscopy, include loss of the typical vascular pattern, granularity, friability, and ulceration.
Once the diagnosis of ulcerative colitis is confirmed, determine whether the inflammation is distal or extensive. Distal disease—that limited to below the splenic flexure—can be treated with topical agents. In contrast, extensive disease, which extends proximal to the splenic flexure, generally requires systemic medication. Clinical and endoscopic findings are also used to define the severity of the disease (Table).
Mild to moderate distal colitis. Oral aminosalicylates, topical mesalamine, and topical corticosteroids are appropriate for patients with mild to moderate distal colitis. Mesalamine enemas or suppositories may be effective in patients with colitis that is refractory to treatment with oral aminosalicylates or topical corticosteroids. If a patient does not respond adequately to maximal doses of all 3 agents, it may be necessary to give prednisone, up to 40 to 60 mg/d, or infliximab, with an induction regimen of 5 mg/kg at weeks 0, 2, and 6.
In patients with proctitis, remission can be maintained by mesalamine suppositories, whereas mesalamine enemas are appropriate for maintaining remission in those with distal colitis. Sulfasalazine, mesalamine compounds, and balsalazide can also be used to maintain remission.
Mild to moderate extensive colitis. Give oral sulfasalazine in daily doses titrated up to 4 to 6 g/d or an alternate aminosalicylate in doses up to 4.8 g/d. Reserve oral corticosteroids for patients whose disease is refractory to oral aminosalicylates (with or without topical therapy) or for those whose symptoms are particularly troublesome. 6-Mercaptopurine or azathioprine is effective in patients who do not respond to oral prednisone, provided they are not so acutely ill that they require intravenous therapy. Infliximab is an option for patients who do not respond to corticosteroids or are dependent on these agents despite adequate doses of a thiopurine or who are unable to tolerate corticosteroids.
1. Kornbluth A, Sachar DB. Ulcerative colitis practice guidelines in adults: American College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol. 2010;105:501-523.
2. Eaden JA, Abrams KR, Mayberry JF. The risk of colorectal cancer in ulcerative colitis: a meta-analysis. Gut. 2001;48:526-535.