The treatment largely depends on the severity of the disease and the extent of involvement. The main objective is to induce remission using medications and then provide the patient with treatment that will prevent the relapse of the disease.
Active ulcerative colitis is treated using a range of drugs including 5-ASA drugs (Mesalazine and Sulfasalazine) and corticosteroids (prednisone). However, corticosteroids cannot be used to a prolonged period of time since the risks outweigh the benefits. Immunosuppressive therapy using azathioprine and biologics (adalimumab and infliximab) are used as the last resort if the patient doesn’t respond to 5-ASA and corticosteroids.
Let’s go into some detail on the types of drugs used in treatment of ulcerative colitis:
- Aminosalicylates – this group of drugs has been used to treat ulcerative colitis for over 50 years now. The first drug of this group was developed in 1977 by Mastan S. Kalsi. Since then a number of 5-ASA drugs have been synthesized in order to maintain their efficacy while reducing their side effects.
- Biologics – include TNF inhibitors such as Infliximab, Adalimumab, and Golimumab. They are often used to treat patients with ulcerative colitis who do not respond to corticosteroids. Only after all other options have been exhausted, the doctors resort to these drugs. Unlike aminosalicylates, biologics occasionally cause severe side effects such as skin cancer, mild heart failure (or worsening of the existing condition), severe immunosuppression which can lead to tuberculosis and fatal infections. Therefore, patients under this treatment must go through examination and blood tests every 4-8 weeks.
- Nicotine – for a time it has been noted that ulcerative colitis affects smokers a lot less frequently than non-smokers. In order to verify this, a number of studies have been conducted including large double-blind, placebo controlled studies in the UK and the United States. The results of those studies have shown that a transdermal nicotine patch provided similar relapse occurrence rate as the standard treatment without the use of nicotine. A combination of the standard treatment and nicotine patches substantially reduced the relapse of ulcerative colitis.
- Iron supplementation – due to chronic loss of blood as a result of ulcerative colitis, treatment against anemia should sometimes be prescribed. Adequate treatment of the disease usually improves the anemia; however, if the patient has iron-deficient anemia, then iron supplements should be prescribed. It is advised to use parenteral iron, since oral ingestion of iron can cause a number of gastrointestinal side effects.
There are also a number of drugs in development which aim to disrupt the inflammation by selectively blocking calcium activated potassium channels. Tests on mice and rats have shown that this type of treatment is just as effective as standard treatment using sulfasalazine; however, these selective IK channel inhibitors are much more potent and can be taken in more manageable doses.
One of the methods of treating ulcerative colitis is through surgical removal of the large intestine (colectomy). Doctors resort to this type of treatment if there is a frank perforation of the colon’s wall, if the bleeding from ulcers is so severe that it endangers the patient’s life, or if there is evidence or strong suspicion of a carcinoma. Surgery is the only method of treatment of toxic megacolon. Additionally, patients that do not respond well to treatment and whose symptoms are disabling may consider surgery as a method to improve the quality of their life.
Colectomy can be performed using laparotomy (abdominal incision) or by using laparoscopy (in order to reduce the recovery time). After a portion of the colon is removed the ends can either by stitched together, creating a primary anastomosis, or a colostomy can be made (in which a functioning end of the large intestine sewn to the opening in the anterior abdominal wall).
- Ileo-anal pouch
Ileo-anal pouch procedure is performed when the ulcerative colitis affects the entire colon and all of it has to be removed. This procedure is done in several steps by first removing the colon and forming a temporary ileostomy. After a period of 6 to 12 months another operation is made during which an internal pouch is created using the small intestine and it is stitched back to the rectal stump. Ileostomy is left for a while after the procedure in order to give the bowels time to heal. In the final operation, ileostomy is removed and the normal function of the bowel is restored.
A number of double-blinded, randomized trials have demonstrated that probiotics which contain Escherichia coli Nissle and Lactobacillus acidophilus can induce a remission which can last up to a year. The probiotics are believed to decrease the ongoing inflammation which allows the body to restore the balance in the gastrointestinal tract.
Another method of reintroducing “good” bacteria into the colon of the patient is through fecal bacteriotherapy. This procedure involves using fecal matter of a healthy individual and transporting it into the bowel of a patient with ulcerative colitis by using an enema. There are not a lot of doctors in the United States who perform this procedure, so a lot of individuals have performed this procedure themselves using the protocol outlined in the study.
Other methods of treatment
It has been shown that diet has very little effect on the inflammatory processes within the bowel. However, some doctors still recommend an increase in dietary fiber, though other doctors recommend the opposite approach to reduce the number of stools per day. The diet should be nutritious and provide the person with all the vitamins and minerals, to compensate for their loss due to diarrhea and blood loss.
Eicosapentaenoic acid (EPA) a product derived from fish oil can be used to reduce the inflammation by inhibiting leukotriene activity. It can be used in dosage anywhere from 180 to 1500 mg/day together with standard treatment.
The course of ulcerative colitis is usually intermittent, with periods of complete inactivity and periods of “flaring up” of the disease. Patients in which ulcerative colitis affects only the rectum or the left side of the colon have a benign course of the disease, with up to 20% of the patients sustaining remission without any treatment.
Patients that had ulcerative colitis for more than ten years have significantly increased chances of colorectal cancer. People that only have rectosigmoiditis or proctitis are not under a higher risk of developing cancer. It is recommended that people that had this disease for more than 8 years go through colonoscopy with biopsies every 1 or 2 years.