Table 1

Overview of common drugs for the treatment of UC

DRUGTIME TO EFFECTROLECOMMENTS
SSZ Salazopyrin2–4 wkAcute and maintenance therapy for UCDose-related side effects; less expensive than 5-ASA
5-ASA (mesalamine)
  Asacol
  Pentasa
  Mesasal
  Salofalk
2–4 wkAcute (higher doses) and maintenance therapy (lower doses) for UC1Often 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 dAcute exacerbations of UC when severe or unresponsive to 5-ASA or SSZHigher 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 moModerate 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 wkAcute 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 hypersensitivityVery 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
Cyclosporine2–3 wkEffective as surgery-sparing agent in acute, severe, steroid-refractory UC; useful as interim therapy while waiting for effect of purine antimetaboliteRarely used with availability of the biologics
Probiotic VSL#3NAMaintenance therapy of mild to moderate UCLimited 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