Therapeutic Progress—reviewix.

Abstract

Ulcerative colitis is a disease of unknown aetiology in which colonic mucosal inflammation and ulceration result in rectal bleeding and diarrhoea. Most patients have relapses separated by long periods of disease inactivity, but a minority of patients have more chronic symptoms. The great majority of a t t x k s of ulcerative colitis settle with prompt medical management but in the few cases where this fails, colectomy is curative although generally leaves the patient with a permanent ileostomy. With good medical and surgical management, mortality from the disease should therefore approach zero. Acute atracksCorticosteroids are the only drugs which have been shown to have an important and unequivocal therapeutic effect in acute attacks of ulcerative colitis (1, 2,3,4). If the disease is confined to the rectum or distal colon, local steroid therapy is often sufficient to obtain a remission (2, 3, 5). It may be given in the form of suppositories, enemas or rectal foam. Suppositories are the simplest to use but are only likely to give adequate drug concentrations in the lower rectum and should therefore only be used in cases of localized distal proctitis. One might imagine that a liquid enema would reach further up the colon than rectal foam but abdominal scanning following rectal instillation of isotopically labelled steroid foam has shown convincingly that it usually passes up to the proximal sigmoid colon and sometimes well into the descending colon (6). In practice, hydrocortisone foam seems at least as effective as hydrocortisone enemas, similar in cost, and generally preferred by the patient (7). It has been shown that approximately half the steroid in enemas containing hydrocortisone or prednisolone-21-phosphate is absorbed (8, 9, 10, l l ) , although it is generally thought that some at least of the therapeutic effect results from the high levels obtained locally in the rectum (10, 11 , 12, 13). Prednisolone metasulphobenzoate sodium is probably as effective as prednisolone-2 1-phosphate when given rectally, but produces much lower free prednisolone levels in the blood (13) and would therefore be expected to cause less adrenal suppression. However, this probably is of little importance clinically if topical steroids are used for a fairly short course of a few weeks or less.