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 |