Ulcerative Colitis: Drug Therapy

Therapy goals

  • Remission induction (achieving disease calming in the acute relapse) and maintenance.
  • Mucosal healing should be aimed for.

Therapy recommendations

Therapy recommendation depending on phase (see above) and intensity:

  • Remission induction:
    • Acute relapse:
      • Mild relapse: mesalazine/5-ASA (anti-inflammatory, i.e., anti-inflammatory bowel therapeutic), oral; in distal colitis (to left flexure/bend of bowel on left side; left-sided colitis): topical therapy.
      • Moderate relapse: additional steroids orally (prednisolone equivalents; glucocorticoids); in distal colitis (to left flexure; left-sided colitis): topical (“local”) therapy
      • Severe/fulminant relapse: systemic steroid therapy (i.v. ), in steroid refractoriness (non-response to steroids/glucocorticoids) additionally ciclosporin (cyclosporin A) or anti-TNF-α antibodies; if necessary. also tacrolimus; if necessary, also ustekinumab (monoclonal antibody; interleukin (IL)-12/23 inhibitor) If it comes under ciclosporin (cyclosporin A)- or anti-TNF-α antibody therapy after seven days at the latest to no response to therapy, a colectomy (surgical removal of the entire colon) must be discussed.
      • Note: In the case of steroid-dependent course, that is, if steroids can not be phased out over three months, therapy escalation to an immunosuppressant or a biologic should take place.
  • Remission maintenance or relapse prophylaxis (measures to prevent recurrence):
    • A systemic glucocorticosteroids should not be used for relapse prophylaxis in the long term!
    • Mild ulcerative colitis: patients who have been placed in remission by mesalazine/5-ASA should receive at least two years of remission-maintaining therapy with mesalazine:
      • For 5-ASA-slow/delayed-release preparations, at least 1.5 g/d.
      • For 5-ASA-MMX formulations, at least 2.4 g/d

      In proctitis or left-sided colitis, 5-ASA clysms or suppositories should be used primarily; in cases of 5-ASA intolerance, the probiotic E. coli strain Nissle 1917 can be given.

    • Moderate and severe ulcerative colitis: in case of steroid dependence or more than one steroid-requiring relapse per year: azathioprine or 6-mercaptopurine (6-MP); duration of therapy at least 2-3 years)); if necessary, also supply of probiotics (supplements with probiotic cultures).
    • Severe i.v.-steroid-refractory ulcerative colitis: primarily anti-TNF-α antibodies (here: infliximab, adalimumab, and golimumab) or cylcosporin A; possibly also ustekinumab (monoclonal antibody; interleukin (IL)-12/23 inhibitor), tofacitinib (JAK inhibitor)Note:
      • Infliximab and calcineurin inhibitors can be used equally in severe refractory ulcerative colitis with or without azathioprine.
      • In extraintestinal manifestations (occurrence of the disease outside the intestine) such as joint symptoms rather resort to TNF antibodies.

    Remission-maintaining therapy with 5-ASA should be at least 2 years if effective.

Further notes

  • In the disease flare-up, the administration of glucocorticoids may also be necessary during pregnancy. The risk to the child experts classify prednisone as low.
  • Definition of severe ulcerative colitis (potentially life-threatening) according to ECCO guidelines:
    • ≥ 6 bloody diarrheas (diarrhea) and
    • Signs of severe systemic illness (fever > 37.8 °C, tachycardia > 90/min, hemoglobin < 10.5 g/dL, ESR elevation > 30 mm/h).

    → inpatient treatment required!

  • Risk of infection with systemic steroid therapy from daily doses of more than 10 mg, cumulative doses of more than 700 mg or with a therapy duration of more than 2 weeks.
  • Note: A common cause of IBD-associated anemia (anemia) is iron deficiency. Iron deficiency anemia: pregnant women ≤ 11 g/dL, nonpregnant women ≤ 12 g/dL, men ≤ 13 g/dL) Iron deficiency anemia (hemoglobin ≥ 10 g/dL):
    • Oral iron substitution; if intolerant or not responding to oral substitution or severe anemia (hemoglobin < 10 /dl / 6.3mmol/l), intravenous administration of iron.
    • Vitamin B 12 substitution should be parenteral (“bypassing the intestine”) in cases of proven vitamin B 12 deficiency anemia.
  • After discontinuation of TNTα-blocker therapy (elective or because of UAW or because of top-down strategy), the incidence rate for recurrence (recurrence of disease) was 17% per patient-year. The median time to relapse after discontinuation of therapy was eleven months. After relapse, clinical remission was achieved in 69-79% by re-treatment with the same TNF-α blocker (infliximab: 79%; adalimumab: 69%).
  • Long-term systemic corticosteroid therapy as relapse prophylaxis should not be performed. Note: In the case of steroid-dependent progression, that is, if steroids cannot be discontinued over three months, therapy escalation to an immunosuppressant or a biologic should occur.

Supplements (dietary supplements; vital substances)

Suitable dietary supplements should contain the following vital substances:

  • Probiotics such as E. coli Nissle and others

    • .

  • Omega-3 fatty acids
  • Gamma-linolenic acid – omega-6 fatty acid

Note: The listed vital substances are not a substitute for drug therapy. Food supplements are intended to supplement the general diet in the particular life situation.