Therapeutic Management in Ulcerative Colitis

Ulcerative colitis is a chronic idiopathic inflammatory disorder of the colon, characterized by a diffuse continuous superficial inflammation that always begins within the rectum and affects the proximal colon to a varying extent. One typical feature of the disease is that it does not involve the small intestine. A small percentage of patientsmay present a superficial inflammation of the terminal ileum. Clinically the disease is associated with rectal bleeding and urgency, tenesmus, abdominal pain and diarrhea. In the assessment of the disease severity, various factors are used, including the frequency of bowel movements, rectal bleeding, laboratory tests, endoscopic extension and appearance and patient’s quality of life.

The treatment of ulcerative colitis is adapted to the disease severity and to the individual patient, no treatment being universally effective. Treatment decisions should be based on disease activity (mild, moderate, severe) and distribution (proctitis, left-sided, extensive colitis) If mild to moderate inflammation is limited to the rectum and for left-sided colitis, the mainstay on the treatment are 5-aminosalicylates, which are highly effective as a topical treatment (suppositories, enemas, foams). Corticosteroids are indicated in patients with more severe disease, and in cases where mesalamine has failed in inducing remission.

For extensive mild to moderate ulcerative colitis, therapy recommendation consists of a combined therapy using oral and topical 5-ASA, which proved to be superior to single use of either. Use of systemic corticosteroids should be considered earlier for patients with extensive colitis and/or treatment failure. For patients with severe ulcerative colitis, hospitalization is generally required. In these cases, steroid therapy is still the gold standard. If there is no improvement in the first 72 hours after the initiation of treatment or symptoms are worsening, second-line conventional therapy must be attempted or proctocolectomymay be considered. In steroid-refractory patients, as well as in patients with severe ulcerative colitis, early introduction of immunosuppressive drugs may be effective during severe episodes, and for the prevention of complications, such as toxic megacolon. Without doubt, the introduction of anti-TNF antibodies have improved the therapeutic options available for patients with ulcerative colitis. But, there still is a substantial amount of patients not responding to anti-TNF antibodies or experiencing a secondary loss of response. Fortunately, for these cases, new classes of drugs have been developed and have been evaluated in early clinical trials.

To illustrate the heterogeneity of cases of ulcerative colitis, we present three particular situations.