Approach to the Medical Therapy of UC
The inflammatory bowel diseases, Crohn's disease and ulcerative colitis, are chronic, relapsing disorders characterized by periods of quiescence and recurrent inflammation. The overall goal of treatment is to halt the inflammatory process and keep it at bay long-term. Treatment for UC consists of medication therapy and, in some patients, surgery if the disease proves to be refractory to medical management. Because UC affects people differently, a variety of factors are taken into consideration when creating an individual treatment plan for each patient. The following provides a brief overview of the key aspects physicians consider when choosing therapies.
1. Phase of Disease
Based upon the relapsing and remitting nature of IBD, disease activity and treatment is divided into 2 phases: Induction of Remission and Maintenance of Remission.
1) Induction of remission: When a person has signs or symptoms of active disease (either at diagnosis or during relapse), potent medications are used to decrease inflammation as quickly as possible and induce remission. As an analogy, you can liken the inflammation of IBD to a bonfire and the medications used to induce remission are akin to buckets of water being dumped over the flames to stamp out the fire. Examples of medications commonly used to induce remission are steroids, infliximab, and cyclosporine.
2) Maintenance of remission: As UC is a chronic disease, medications are required to maintain remission of disease once an acute flare has been controlled. These may be the same medications used to induce remission, or others which are selected due to lower toxicity long-term. Examples of medications used for maintenance of remission are: 5-ASA drugs (sulfasalazine, mesalamine), azathioprine, 6-mercaptopurine, and infliximab.
2. Extent and Severity of Disease
1) Extent of disease: UC universally involves the rectum and may extend to involve part or the entire colon. If only a limited portion is involved at the end of the colon/rectum the disease is termed “proctosigmoiditis”; if the disease progresses and affects the entire colon it is called “pancolitis”. The extent of disease guides the choice of medication in that disease limited to the very bottom of the rectum may be effectively treated with enema preparations, as opposed to more extensive disease which requires the use of oral medicines.
2) Severity of disease: The severity of UC varies among individuals and can change over the course of a person’s disease. Typically, disease severity is categorized as mild, moderate, or severe. The severity of disease may alter the choice of medications used to treat UC as more severe disease is treated with medications of greater potency.
3. History of Disease
Choice of medication may also be affected by the duration of disease and number of relapses/flares a patient has experienced. Medications used on initial presentation of disease may be changed later in the course depending on the number and intensity of relapses.
4. Other Considerations
Outside of specific disease characteristics, other considerations for choice of medical therapy may be impacted by patient drug allergies, tolerability, and cost.