Treating ulcerative colitis

Treatment for ulcerative colitis depends on how severe the condition is and how often your symptoms flare up.

The main aims of treatment are to:

• reduce symptoms, known as inducing remission (a period without symptoms)
• maintain remission

This usually involves taking various types of medication, although surgery may sometimes be an option.

Your treatment will normally be provided by a range of healthcare professionals, including:

• specialist doctors such as gastroenterologists or surgeons
• GPs
• specialist nurses

Your care will often be co-ordinated by your specialist nurse and your care team, and they'll usually be your main point of contact if you need help and advice.

The various treatments forulcerative colitisare outlined below. You can also read a summary of the pros and cons of the treatments for ulcerative colitis , allowing you to compare your treatment options.

Aminosalicylates

Aminosalicylates (5-ASAs), such as sulphasalazineor mesalazine, are medications that help toreduce inflammation. They're usually the first treatment option for mildor moderate ulcerative colitis.

5-ASAs can be used as a short-term treatment for flare-ups. They can also be taken long term, usually for the rest of your life,to maintain remission.

5-ASAscan be taken:

• orally byswallowing a tablet or capsule
• as a suppository a capsule that you insert into your rectum (bottom), where it dissolves
• through an enema where fluid is pumped into your large intestine

How you take 5-ASAs depends on the severity and extent of your condition.

These medications rarely haveside effects, but some people may experience:

• Headaches
• feeling sick
• abdominal (tummy) pain
• a rash
• rarely, diarrhoea

Corticosteroids

Corticosteroids , such as prednisolone,are amore powerful type of medication used to reduce inflammation. They can be used with or instead of 5-ASAs to treat a flare-upif 5-ASAs alone aren't effective.

Like5-ASAs, steroids can be administered orally, or through a suppository or enema.

However, unlike 5-ASAs, corticosteroids aren't used as a long-term treatment to maintain remission because they cancause potentially serious side effects, such as osteoporosis (weakening of the bones) and cataracts (cloudy patches in the lens of the eye) when used for a long time.

Side effects of short-term steroid use can include:

• acne
• weight gain
• increased appetite
• mood changes (such as becoming more irritable)
• insomnia (difficulty sleeping)

They're usually given as tablets to treat mild or moderate flare-ups, or maintain remission if your symptoms haven't responded to other medications.

Immunosuppressants can be very effective in treating ulcerative colitis, but they oftentake a while to start working (usually between two and three months).

The medicinescan make you morevulnerable to infection, so it's important to report any signs of infection, such asfever or sickness, promptly to your GP.

They can also lower the production of red blood cells, making you prone to anaemia . You'llneed regular blood tests to monitor your blood cell levels and to check for any other problems.

Treating severe flare-ups

While mild or moderate flare-ups can usually be treated at home, more severe flare-upsshould be managedin hospital to minimise the risk of dehydration and potentially fatal complications, such as your colon rupturing.

In hospital, you'll be given medication and sometimes fluids intravenously (directly into a vein). The medication you have will usually be a type of corticosteroid or an immunosuppressant medication called infliximab orciclosporin.

Ciclosporin

Ciclosporin works in the same way as other immunosuppressant medications (see above)by reducing the activity of the immune system. However, it's more powerful than the medications used to treat milder cases of ulcerative colitis and starts to work much sooner (normally withina fewdays).

Ciclosporinis given slowly through a drip in your arm (known as an infusion) and treatment will usually be continuous, for around seven days.

Side effects of intravenous ciclosporin can include:

• a tremor (an uncontrollable shaking or trembling of part of the body)
• excessive hair growth
• fatigue (extreme tiredness)
• swollen gums
• feeling and being sick
• diarrhoea

Ciclosporin can also causemore serious problems such as high blood pressure and reduced kidney and liver function, but you will be monitoredregularlyduring treatment to check for signs of these.

Biologic medications

Infliximab, adalimumab, golimumab and vedolizumab are medications that reduce inflammation of the intestineby targeting proteins which the immune system uses to stimulate inflammation. These medications block these receptors and reduce inflammation.

They may be used to treat adults with moderate to severe ulcerative colitis, if other options aren't suitable or working. Infliximab may also be used to treat children or young people aged 6-17 with severe ulcerative colitis (see below).

The treatment is given for 12 months unless the medication isn't working well.

Read the full NICE guidelines on:

• infliximab, adalimumab and golimumab for treating moderately to severely active ulcerative colitis after the failure of conventional therapy
• vedolizumab for treating moderately to severely active ulcerative colitis

Infliximab

Infliximab is given as an infusion over the course of one to two hours. You'll be given further infusions after two weeks, and again after six weeks. Infusions are then given every eight weeks, if treatment is still required.

Common side effects of infliximab can include:

• increased risk of infectionreport any symptoms of a possible infection, such as coughs , high temperature or sore throat , to your GP
• vertigo (the sensation you or the environment around you is moving) and dizziness
• an allergy -like reaction, causing breathing difficulties, urticaria (hives)and headaches

In most cases,a reaction to the medication occurs in the first two hours after the infusion has finished. However, some people experience delayed reactions days, or even weeks, after an infusion. If you begin to experience the symptoms listed above after having infliximab, seek immediate medical assistance.

You'll be carefully monitored after your first infusion and, if necessary, powerful anti-allergy medication, such as epinephrine, may be used.

Infliximab isn't usuallysuitable for people with a history of tuberculosis (TB) or hepatitis B and needs to be used with caution in those with HIV or hepatitis C . This isbecause there havebeen a number of cases where infliximab has "reactivated" dormant infections.The medicationis also not recommended for people with a history of heart disease or multiple sclerosis .

Surgery

If you have frequent flare-ups that have a significant effect on your quality of life, or you have a particularly severe flare-up that isn't responding to medication, surgery may be an option.

Surgery for ulcerative colitisinvolves permanently removing the colon(known as a colectomy).

During the operation, your small intestine will be used to pass waste products out of your body instead of your colon. Thiscan be achieved by creating:

• an ileostomy where the small intestine is diverted out of a hole made in your abdomen. Special bags are placed over this opening, to collect waste materials after the operation
• an ileo-anal pouch (also known as a J-pouch) where part of the small intestine is used to create an internal pouch thatis then connected to your anus, allowing you to pass stools normally

Ileo-anal pouches are increasingly used because an external bag to collect waste products isn't required.

As the colon is removed, ulcerative colitis can't recur after surgery. However, it's important to consider the risks of surgery and the impact ofhaving a permanent ileostomy or ileo-anal pouch.

Antidiarrhoeals

Antidiarrhoeal medicine is used to treat diarrhoea. For example, dicyclomine.

Corticosteroids

Corticosteroid is a naturally occurring hormone produced by the adrenal gland, or a synthetic hormone having similar properties. It is used to reduce inflammation, so reducing swelling and pain.

Enemas

An enema is an injection of fluid into the large intestine / colon to empty the bowel. It can also be used to make the bowels show up more clearly in an X-ray.

Inflammation

Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.

Intravenous

Intravenous (IV) means the injection of blood, drugs or fluids into the bloodstream through a vein.

Remission

Remission is when the symptoms of a condition are reduced (partial remission) or go away completely (complete remission).