When you have ulcerative colitis (UC), the goal of treatment is to stop your immune system from attacking the lining of your intestine. This will bring down the inflammation causing your symptoms and put you into remission.
Your doctor can choose from several different types of medications to help you achieve these goals.
In the past few years, the number of drugs used to treat UC has increased. Researchers are studying other new and possibly improved treatments in clinical trials.
A few different types of medication are available to help treat UC. Your doctor will help you choose one of these therapies based on:
- whether your disease is mild, moderate, or severe
- which drugs you’ve already taken
- how well you responded to those medications
- your overall health
Aminosalicylates (5-ASA drugs)
This group of drugs contains the ingredient 5-aminosalicylic acid (5-ASA). They include:
- mesalamine (Apriso, Asacol HD, Canasa, Pentasa)
- olsalazine (Dipentum), which is only available as a brand-name drug
- balsalazide (Colazal)
- sulfasalazine (Azulfidine)
When you take these drugs by mouth or as an enema, they help bring down inflammation in your intestine. Aminosalicylates work best for mild-to-moderate UC, and they can help prevent flare-ups.
The American Gastroenterological Association (AGA) strongly recommends that adults with extensive mild-to-moderate UC choose standard-dose oral mesalamine, olsalazine, or balsalazide instead of low-dose mesalamine, sulfasalazine, or no treatment.
A standard dose of mesalamine is 2 to 3 grams (g) per day.
Corticosteroids suppress the immune system to bring down inflammation. Examples include:
- prednisone (Prednisone Intensol, Rayos)
- prednisolone (Prelone, Millipred)
- methylprednisolone (Medrol)
- budesonide (Uceris)
Your doctor may prescribe one of these drugs short-term to calm a symptom flare.
You may take them in a variety of ways:
- by mouth
- as an injection
- by intravenous (IV) infusion
- as a rectal foam
It’s not a good idea to stay on steroids in the long term, because they can cause problems such as:
- high blood sugar
- weight gain
- bone loss
Immunomodulators suppress your immune system to prevent it from causing inflammation. You may start taking one of these medications if aminosalicylates haven’t helped your symptoms.
Examples of immunomodulators include:
- azathioprine (Azasan, Imuran)
- mercaptopurine (Purixan)
- methotrexate (Otrexup, Trexall, Rasuvo)
According to a 2018 study, methotrexate may not be effective at helping people with UC remain in remission.
People who take methotrexate also have an increased risk of stomach and intestinal problems.
Immunomodulators haven’t been approved by the Food and Drug Administration (FDA) for the treatment of UC. However, your doctor may still prescribe them off label.
OFF-LABEL DRUG USE
Off-label drug use is when a drug that’s approved by the FDA for one purpose is used for a different purpose that hasn’t yet been approved.
However, a doctor can still use the drug for that purpose. This is because the FDA regulates the testing and approval of drugs, but not how doctors use drugs to treat their patients.
So your doctor can prescribe a drug however they think is best for your care.
Biologics are made from genetically engineered proteins or other natural substances. They act on the specific parts of your immune system that drive inflammation.
Anti-TNF drugs block tumor necrosis factor (TNF), an immune system protein that triggers inflammation. TNF blockers can help people with moderate-to-severe UC whose symptoms haven’t improved while they were taking other medications.
TNF blockers include:
- adalimumab (Humira)
- golimumab (Simponi)
- infliximab (Remicade)
Adalimumab and golimumab are given by subcutaneous injection, while infliximab is given by IV infusion.
Vedolizumab (Entyvio) is also used to treat moderate-to-severe disease. It stops damaging white blood cells (WBCs) from entering your gastrointestinal tract and causing symptoms such as inflammation.
Vedolizumab is given by IV infusion.
Choosing a biologic
The AGA suggests that people who have moderate-to-severe UC and are new to biologics choose infliximab or vedolizumab over adalimumab. Infliximab and vedolizumab are more effective.
However, some people may find adalimumab to be more convenient, since it can be self-administered. The other biologics must be administered by a healthcare professional.
It’s fine to choose adalimumab if you’d prefer a self-injectable medication or if you otherwise find it to be more accessible or affordable than the other biologics.
If the treatment you’ve tried hasn’t helped to control your symptoms or it stops working, you may need surgery. There are multiple types of surgery for UC.
Proctocolectomy is the most common type. In this procedure, the entire rectum and colon are removed in order to prevent further inflammation.
After surgery, you won’t have a colon to store wastes. Your surgeon will create a pouch inside of your body from part of your small intestine (ileum). The internal pouch will collect your waste.
The procedure used to create the internal pouch is known as an ileostomy.
In addition to the internal pouch, you’ll also have an external waste bag (ostomy bag) or a catheter. Whether you have an ostomy bag or a catheter is determined by the type of ileostomy that you receive.
Surgery is a big step, but it’ll help to relieve the symptoms of UC.
In the last few years, a few new UC medications have emerged.
The biologic ustekinumab (Stelara) was approved by the FDA in October 2019. It works by targeting two inflammatory proteins, IL-12 and IL-23.
The first dose of ustekinumab is given by IV infusion. Later doses are given as an IV infusion.
Biosimilars are a relatively new class of drugs that are designed to mimic the effects of biologics. Like biologics, these drugs target immune system proteins that contribute to inflammation.
Biosimilars work in the same way as biologics, but they may cost much less. Four letters are added to the end of the name to help distinguish the biosimilar drug from the original biologic.
The FDA has approved several biosimilars for UC in the last few years. They’re modeled after Humira or Remicade and include:
- adalimumab-adaz (Hyrimoz), FDA approved in October 2018
- adalimumab-adbm (Cyltezo), FDA approved in August 2017
- adalimumab-afzb (Abrilada), FDA approved in November 2019
- adalimumab-atto (Amjevita), FDA approved in September 2016
- adalimumab-bwwd (Hadlima), FDA approved in July 2019
- adalimumab-fkjp (Hulio), FDA approved in July 2020
- infliximab-abda (Renflexis), FDA approved in May 2017
- infliximab-axxq (Avsola), FDA approved in December 2019
- infliximab-dyyb (Inflectra), FDA approved in April 2016
The Remicade biosimilars are the only ones currently available for purchase in the United States. The Humira biosimilars aren’t available yet because the patent held by Humira’s manufacturer hasn’t expired.
Tofacitinib (Xeljanz) belongs to a class of medications known as Janus kinase (JAK) inhibitors. These drugs block the enzyme JAK, which activates cells of the immune system to produce inflammation.
Xeljanz has been FDA approved since 2012 to treat rheumatoid arthritis (RA) and since 2017 to treat psoriatic arthritis (PsA). In 2018, the FDA also approved it to treat people with moderate-to-severe UC who haven’t responded to TNF blockers.
This drug is the first long-term oral treatment for moderate-to-severe UC. Other drugs require an infusion or injection.
Side effects from Xeljanz include:
- high cholesterol
Researchers are constantly searching for better ways to control UC. Here are a few new treatments under investigation.
A fecal transplant, or stool transplant, is an experimental technique that places healthy bacteria from a donor’s stool into the colon of someone with UC. The idea may sound unappealing, but the good bacteria help heal damage from UC and restore a healthy balance of germs in the gut.
Stem cell therapy
Stem cells are the young cells that grow into all of the various cells and tissues in our bodies. They have the potential to heal all kinds of damage if we harness and use them correctly.
In UC, stem cells may alter the immune system in a way that helps bring down inflammation and heal damage.
Doctors have a wider range of treatment options for UC than ever before. Even with so many drugs, some people have trouble finding one that works for them.
Researchers are constantly studying new treatment approaches in clinical trials. Joining one of these studies can give you access to a drug before it’s available to the public. Ask the doctor who treats your UC if a clinical trial in your area might be a good fit for you.
The outlook for people with UC is much better today, thanks to new drugs that can calm intestinal inflammation. If you’ve tried a drug and it didn’t help you, know that other options may improve your symptoms.
Be persistent, and work closely with your doctor to find a therapy that ultimately works for you.