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Ulcerative Colitis


Mild to Moderate Disease

  • The first line of drug therapy for the patient with mild to moderate colitis is oral sulfasalazine or an oral mesalamine derivative, or topical mesalamine or steroids for distal disease.
  • When given orally, usually 4 g/day, up to 8 g/day of sulfasalazine is required to attain control of active inflammation. Sulfasalazine therapy should be instituted at 500 mg/day and increased every few days up to 4 g/day or the maximum tolerated.
  • Oral mesalamine derivatives are reasonable alternatives to sulfasalazine for treatment of ulcerative colitis but they are not more effective than sulfasalazine.
  • Steroids have a place in the treatment of moderate to severe ulcerative colitis that is unresponsive to maximal doses of oral and topical mesalamine. Prednisone up to 1 mg/kg/day may be used for patients who do not have an adequate response to sulfasalazine or mesalamine.
  • Steroids and sulfasalazine appear to be equally efficacious; however, the response to steroids may be evident sooner.
  • Rectally administered steroids or mesalamine can be used as initial therapy for patients with ulcerative proctitis or distal colitis.
  • Transdermal nicotine in the highest tolerated dose improved symptoms of patients with active ulcerative.
TABLE. Mesalamine Derivatives for Treatment of Inflammatory Bowel Disease
Product Trade Name(s) Formulation Dose/Day Site of Action
Sulfasalazine Azulfidine Tablet 4– 6 g Colon
Mesalamine Rowasa, Salofalk, Claversal, Pentasa Enema 1– 4 g Rectum, terminal colon
Asacol Mesalamine tablet coated with Eudragit-S (delayed-release acrylic resin) 2.4– 4.8 g Distal ileum and colon
Pentasa Mesalamine capsules encapsulated in ethylcellulose microgranules 2– 4 g Small bowel and colon
Olsalazine Dipentum Dimer of 5-aminosalicylic acid oral 1.5– 3 g Colon
Balsalazide Colazal capsule 6.75 g Colon

Severe or Intractable Disease

  • Patients with uncontrolled severe colitis or incapacitating symptoms require hospitalization for effective management. Most medication is given by the parenteral route.
  • With severe colitis, there is a much greater reliance on parenteral steroids and surgical procedures. Sulfasalazine or mesalamine derivatives have not been proven beneficial for treatment of severe colitis.
  • Steroids have been valuable in the treatment of severe disease because the use of these agents may allow some patients to avoid colectomy. A trial of steroidsis is warranted in most patients before proceeding to colectomy, unless the condition is grave or rapidly deteriorating.
  • Continuous intravenous infusion of cyclosporine (4 mg/kg/day) is recommended for patients with acute severe ulcerative colitis refractory to steroids.

Maintenance of Remission

  • Once remission from active disease has been achieved, the goal of therapy is to maintain the remission.
  • The major agents used for maintenance of remission are sulfasalazine (2 g/day) and the mesalamine derivatives, although mesalamine is not as effective as sulfasalazine.
  • Steroids do not have a role in the maintenance of remission with ulcerative colitis because they are ineffective. Steroids should be gradually withdrawn after remission is induced (over 3 to 4 weeks). If they are continued, the patient will be exposed to steroid side effects without likelihood of benefits.
  • Maintenance of remission is well documented up to 1 year and may last as long as 3 years.
  • Azathioprine is effective in preventing relapse of ulcerative colitis for periods of up to 2 years. However, 3 to 6 months may be required for beneficial effect.

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