Update on the Management of Ulcerative Colitis

Abstract

The treatment options for inflammatory bowel disease have expanded with the introduction of biological therapies. Recently published controlled clinical trials were searched and those that impact the clinical management of ulcerative colitis (UC) are discussed in this review. In the management of mild to moderate UC, mesalamine still remains the first choice of drug. The newly developed once daily formulations have shown equal efficacy to divided doses and possibly portend better compliance owing to a simplified regimen. In outpatients with moderate to severe UC, recent data indicate that infliximab induced and maintained remission leads to decreased colectomy rates and fewer hospitalizations. An alternative anti-tumor necrosis factor (TNF) agent, adalimumab, was also recently shown to be effective for induction of remission in moderate to severe UC. The use of immunosuppressives, such as azathioprine and mercaptopurine, is associated with decreased colectomy rates and thioguanine was shown to be effective in maintaining clinical remission in those who are intolerant to azathioprine/mercaptopurine. In hospitalized patients with steroid resistant severe UC, infliximab and tacrolimus may be alternatives to cyclosporine in those who are otherwise candidates for colectomy. Adequate long-term maintenance therapy with immunosuppressives or anti-TNF therapy is required after rescue therapy for a sustained benefit. Future research is needed to position the available anti-TNF agents and combined immunosuppressive therapy in the treatment of UC to achieve and maintain steroid free remission.

Clinical audit: recent practice in caring for patients with acute severe colitis compared with published guidelines – is there a problem?

“…Interestingly, despite high prevalence being reported elsewhere (North America and Europe), no patients in our cohort tested positive for C. difficile . Regardless, it remains important to exclude bacterial pathogens in every episode of ASC as intensifying immmunosuppression in the face of colonic infection can lead to dire circumstances and increase the risk of colectomy …”

“…14 Most (90%) of our cohort underwent colonic examination; however, CMV was excluded on biopsy in only 40% of admissions. Much evidence has surfaced implicating CMV infection in refractory ASC, 15 demonstrating CMV to be a risk factor for colectomy. [16][17][18][19] The importance of concurrent CMV infection was seen in one patient who initially improved but then rapidly declined, eventually coming to colectomy despite IV Aciclovir.…”

“…Regardless, it remains important to exclude bacterial pathogens in every episode of ASC as intensifying immmunosuppression in the face of colonic infection can lead to dire circumstances and increase the risk of colectomy. 15,[21][22][23] Management of ASC requires the expertise of a multidisciplinary team, preferably led by a gastroenterologist. 6 First-line management of ASC is generally IV steroids.…”

How the Discovery of TNF-α Has Advanced Gastrointestinal Diseases and Treatment Regimes

“…In the past few decades, the mainstays of treatment have been systemic and topical corticosteroids and 5-aminosalicylates (5-ASA), and immunomodulators such as 6-mercaptopurine (6-MP), azathioprene, cyclosporine, and methotrexate. Although inexpensive and generally well tolerated, steroids are unsuitable for longterm use, 5-ASA are mostly useful only for mild-moderate disease, and 6-MP and azathioprene are incapable of inducing clinical remission, whereas cyclosporine, though useful in acute severe disease, is not suitable for chronic treatment [30]. Infliximab was the first biological inhibitor of TNF-a to be approved for treatment of IBD (reviewed in [31]).…”

Long‐term outcome of cyclosporin rescue therapy in acute, steroid‐refractory severe ulcerative colitis

“…Corticosteroids have been the primary therapies in moderate to severe UC for years. Those who fail to respond to treatment with corticosteroids, or who present with severely active UC, should be considered as candidates for rescue treatment 1 . Our previous work revealed that anaemia, need for blood transfusion, and frequency of previous hospitalizations significantly determines the response to early parenteral corticosteroid therapy.…”