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Ulcerative colitis (UC) is an inflammatory bowel disease that causes long-term inflammation and ulcers in the digestive tract, particularly in the innermost lining of your colon and rectum. This is one of the most common conditions I treat—nearly 700,000 people in the United States are affected by it.
Symptoms of UC can be isolated to gastrointestinal only or with other unrelated symptoms because the inflammation can affect any part of your body. Symptoms might include:
- Bloody stools
- Nocturnal diarrhea, or waking at night due to bowel movements
- Severe arthritis, or joint inflammation
- Skin rashes
- Tenesmus, or severe urgency with feelings of incomplete evacuation
- Uveitis or episcleritis, or eye inflammation
- Weight loss
Ulcerative colitis is an auto-inflammatory condition in individuals with a genetic predisposition, meaning they have an increased likelihood of developing a particular disease based on their individual genetic makeup. The inflammation also can be triggered by external factors, such as antibiotics, food additives and preservatives, and infection.
There’s no known cure for UC yet. However, the right balance of medications, and sometimes surgery if needed, can significantly reduce symptoms and even provide long-term remission for patients.
LISTEN: Dr. Malhotra discusses ulcerative colitis symptoms and treatment in the Medical Intel podcast.
What Ulcerative Colitis Treatments are Available?
If a patient is diagnosed with UC, medication is the most common treatment method we recommend. There are several effective medications, to help relieve symptoms and even bring about remission. Every patient’s severity of symptoms and the way they react to medications is different. A discussion with a doctor will help determine which treatment option is best.
4 Types of Medication for Ulcerative Colitis
1. Mesalamine: Mesalamine diminishes inflammation by blocking the production of substances that cause inflammation (cyclooxygenase and prostaglandin). This is a time-tested drug that we use as a first-line therapy for mild to moderate disease.
2. Immunomodulators: These include azathioprine or mercaptopurine (6-MP), which inhibit purine synthesis. Purines are building blocks for DNA and RNA. By inhibiting purine synthesis, less DNA and RNA are produced for the synthesis of white blood cells, thus causing immunosuppression. Decreasing the immune system causes decreased inflammation over time. We are starting to steer away from using these as first-line medications, as better and improved drugs—such as biologics—become available on the market.
3. Biologics: There are currently multiple biologics in the market that which belong to three different class of drugs, meaning two different mechanisms of action. Infliximab, adalimumab, and golimumab belong to the anti-TNF-α class of action and have been on the market the longest. These medications reduce inflammation quickly and effectively and help heal the lining of the colon. Since we started using them roughly 18 years ago, fewer patients now require surgery for UC. Vedolizumab, which belongs to anti-integrin class was approved in 2014 and has continued to show excellent results in addition to improved safety profile.
4. Small molecules: Tofacitinib, which is an oral medication, was approved by the FDA in May 2018 for the treatment of UC. This is the next step in effective therapies with improved ease of taking the medication. The oral pill is taken twice daily. Tofacitinib is a JAK-inhibitor, which targets and blocks a signaling pathway in the inflammation. Being that it is a relatively new medication, the long-term effects are uncertain.
Removing the colon, or total-proctocolectomy, is an effective treatment, usually reserved for patients who do not respond to medications or have rapidly progressive disease. But it can have complications. One issue patients can still have after surgery is primary sclerosing cholangitis (PSC), or inflammation of the bile ducts. This can occur as a complication of ulcerative colitis, even years after the colon is removed. So, it’s important for patients to follow up with their doctor at least once a year to be under surveillance for this.
Patients can experience symptoms of the disease in one of the following ways:
- Mild, which may only involve part of their colon or the entire colon.
- Mild, but at some point—gradually or sometimes suddenly—worsens to severe disease.
- Severe, or even what we call fulminant disease, where they need immediate hospitalization, aggressive therapy, and sometimes even surgery.
When to See a Doctor
If left untreated, ulcerative colitis can cause debilitating short-term and long-term symptoms that could affect not only a person’s work performance and attendance, but also their social and family life. Severe cases in the short-term have led to patients needing emergency surgery and hospitalization because of a toxic megacolon, in which the colon is infected and swells up. Sometimes patients can have refractory bleeding, in which the patient might experience massive blood loss from the colon requiring urgent surgery.
Over the long term, untreated ulcerative colitis can increase the risk of colon cancer by almost eight-fold. Furthermore, patients with UC are at increased risk of developing primary sclerosing cholangitis (PSC), or the inflammation and scarring of the bile ducts, which puts patients at risk for bile duct cancer (cholangiocarcinoma) and gallbladder cancer.
Another reason to see a doctor is the risk of having concurrent infections such as clostridium difficile (C. diff), a dangerous bacterium that’s increasing in the community. A patient’s risk of developing C. diff increases significantly when they have UC. Moreover, the presence of C. diff makes UC more difficult to treat and increases the risk of hospitalization and needing an emergency colectomy.
It’s important that patients experiencing symptoms of ulcerative colitis schedule an appointment with a doctor. The doctor will find the best treatment option personalized for each patient and ensure any underlying diseases are managed as well.