Navigating the complexity of ulcerative colitis: Challenging case example

Mark Lees; Loren Regier; Brent Jensen

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Table 1

Overview of common drugs for the treatment of UC

DRUG	TIME TO EFFECT	ROLE	COMMENTS
SSZ Salazopyrin	2–4 wk	Acute and maintenance therapy for UC	Dose-related side effects; less expensive than 5-ASA
5-ASA (mesalamine) Asacol Pentasa Mesasal Salofalk	2–4 wk	Acute (higher doses) and maintenance therapy (lower doses) for UC¹	Often better tolerated than SSZ All oral formulations are active in rectum and proximal and distal colon; some products are also active higher in the gastrointestinal tract. Foam, enema, and rectal suppository formulations are useful for distal or rectal disease. Effective reach of effect: suppository: 10 cm foam: 15–20 cm enemas: splenic flexure² Foam might be preferred for patients who have difficulty retaining enemas
Corticosteroids Prednisone, oral Budesonide (Entocort) Hydrocortisone (Cortifoam, Hycort, Cortenema) Hydrocortisone, IV (Solu-Cortef) Methylprednisolone, IV (Solu-Medrol)	< 7–14 d	Acute exacerbations of UC when severe or unresponsive to 5-ASA or SSZ	Higher initial doses required until clinical improvement is seen, then taper gradually and discontinue; other maintenance agents safer for maintenance of remission Oral or IV administration; IV administration useful in more severe or fulminant disease Anti-inflammatory dose equivalency: prednisone 5 mg = methylprednisolone 4 mg = hydrocortisone 20 mg Topical enemas and foams useful for distal colon and rectal disease Budesonide less bioavailable than prednisone; less effective, fewer side effects, more expensive
Purine antimetabolites AZA (Imuran) 6MP (Purinethol)	3–6 mo	Moderate to severe UC, for patients not responding to corticosteroids and for those unable to adequately wean from corticosteroids (eg, steroid sparing)	Maintenance doses are the same as induction doses Requires monitoring of CBC, LFTs, and for symptoms of pancreatitis Methotrexate lacks evidence in UC but can be tried if AZA is ineffective or not tolerated³
Biologic response modifiers (TNFα inhibitors) Infliximab (Remicade) Adalimumab (Humira)	Within 2 wk	Acute and maintenance therapy for UC in moderate to severe disease that is not responsive to standard treatment; avoid in active infection, acute heart failure, or hypersensitivity	Very effective in some, but also considerable potential harms, including increased risk of infection (eg, viral [especially varicella], fungal, or bacterial and reactivation of tuberculosis or hepatitis B), infusion reactions (especially with infliximab),⁴ and rare lymphoma or drug-induced lupus. Recent meta-analysis found that in the short term, biologics had a higher rate of total adverse reactions vs control (NNH = 30, 95% CI 21–60), but the rate of serious adverse events was not different.⁵ Long-term research is lacking
Cyclosporine	2–3 wk	Effective as surgery-sparing agent in acute, severe, steroid-refractory UC; useful as interim therapy while waiting for effect of purine antimetabolite	Rarely used with availability of the biologics
Probiotic VSL#3	NA	Maintenance therapy of mild to moderate UC	Limited evidence suggests benefit in maintenance therapy of mild to moderate UC⁶

5-ASA—5-aminosalicylic acid, 6MP—mercaptopurine, AZA—azathioprine, CBC—complete blood count, CI—confidence interval, IV—intravenous, LFT—liver function test, NNH—number needed to harm, SSZ—sulfasalazine, TNF—tumour necrosis factor, UC—ulcerative colitis.
Adapted from Sutherland and MacDonald.⁷

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This data supplement contains an Inflammatory Bowel Disease chart.

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