Living with ulcerative colitis can be distressing, with your daily routine disrupted by frequent bathroom trips and unpleasant gastrointestinal symptoms. Ulcerative colitis is a chronic disease that causes inflammation in the inner lining of the rectum and, to varying degrees, the colon. Sores, or ulcers, develop in the lining from the inflammation, causing bleeding and diarrhea. It’s thought that an abnormal immune reaction in the intestines triggers the inflammation.
Two major medical organizations, the American Gastroenterological Association (AGA) and the American College of Gastroenterology (ACG), recently updated their guidelines for managing the disease. The guidelines emphasize the importance of involving patients in treatment decisions. There’s no one-size-fits-all approach to treatment, and any decision should be made jointly between doctor and patient.
Mild to moderate colitis
Mild to moderate ulcerative colitis is often characterized by periods of disease activity followed by periods of remission. Signs and symptoms of mild to moderate ulcerative colitis include no more than four to six bowel movements a day, mild to moderate rectal bleeding, urgency and incontinence, and lower levels of overall inflammation in the rectum and colon than those associated with severe ulcerative colitis. Unlike severe colitis, mild to moderate colitis doesn’t cause so-called extra-intestinal symptoms such as fever, weight loss, fatigue, or malaise.
In February 2019, the AGA published its guidelines on the management of mild-to-moderate ulcerative colitis in Gastroenterology. The goal of treatment is to achieve sustained remission by healing the damage done to the intestinal lining by inflammation. The AGA recommends a class of drugs called aminosalicylates, often shortened to 5-ASAs (for their active ingredient, 5-aminosalicylic acid) as the mainstay reatment for mild to moderate ulcerative colitis. Two closely related drugs from a group known as diazo-bonded 5-ASAs are also available.
All the drugs come in pill, enema, and suppository forms and are sometimes more effective when combined, depending on the severity of the disease. If ulcerative colitis is difficult to control, a short course of corticosteroids may be prescribed.
Moderate to severe colitis
Symptoms of severe colitis, which can often be debilitating, include loose and bloody stools six or more times a day, severe abdominal cramping, urgent bowel movements, nausea, anorexia and weight loss, fever, rapid heart rate, and fatigue. The ACG guidelines, published in March 2019 in the American Journal of Gastroenterology, recommend biologic drugs for people with moderate to severe colitis who don’t respond to 5-ASAs or corticosteroids, who become dependent on corticosteroids, or who have repeated flare-ups.
Biologics replicate natural substances in our bodies. Those used for ulcerative colitis target specific parts of the immune system. One downside of biologics is that they increase infection risk.
Biologics include a class of drugs called anti-TNFs, which block the activity of a protein in the blood and the intestine that stimulates inflammation. They are self-injected or administered intravenously. Anti-TNFs may be combined with another class of drug called immunomodulators.
The FDA recently approved another biologic drug, tofacitinib (Xeljanz), which can be taken orally, for the treatment of moderate to severe ulcerative colitis.
It’s important to know that the absence of ongoing colitis symptoms doesn’t necessarily mean that the lining of the colon has returned to normal, so don’t stop medications without your doctor’s approval.
Some people with ulcerative colitis turn to alternative remedies, including dietary supplements containing curcumin, a plant chemical with antioxidant properties found in the spice turmeric. Probiotics, which are supplements packed with “healthy” bacteria often marketed to aid digestion, are another choice.
However, both the AGA and ACG guidelines say there’s too little evidence from clinical studies to establish whether over-the-counter curcumin and probiotics relieve ulcerative colitis symptoms or are effective in healing the inflammation.
Both guidelines are somewhat more optimistic about another emerging novel therapy, fecal microbiota transplants, in which bacteria from the stool of a healthy donor is infused into the gut of a patient with ulcerative colitis. While a few studies suggest fecal transplants hold promise, more refinement and studies need to be done. The AGA suggests that people with ulcerative colitis should only pursue this treatment as part of a clinical trial.
A note on colitis and colon cancer
Ulcerative colitis increases the risk for colorectal cancer, so patients require colonoscopy screening to prevent this malignancy. The ACG recommends the following screening schedule for most people with ulcerative colitis:
- Screening should begin eight years after initial diagnosis.
- Thereafter, patients should be screened every one to three years, depending on additional risk factors, such as age, the extent of inflammation, the degree of intestinal healing, disease duration, and family history of colorectal cancer.
- Patients who also have a condition called primary sclerosing cholangitis (inflammation of the bile ducts) should be screened when diagnosed with ulcerative colitis, then annually.
This article first appeared in the July 2019 issue of UC Berkeley Health After 50.
Also see The ABCs of IBS.