Ulcerative colitis is a lifelong inflammatory disease affecting the rectum and colon to a variable extent. In 2023, the prevalence of ulcerative colitis was estimated to be 5 million cases around the world, and the incidence is increasing worldwide. Ulcerative colitis is thought to occur in people with a genetic predisposition following environmental exposures; gut epithelial barrier defects, the microbiota, and a dysregulated immune response are strongly implicated. Patients usually present with bloody diarrhoea, and the diagnosis is based on a combination of clinical, biological, endoscopic, and histological findings. The aim of medical management is, first, to induce a rapid clinical response and normalise biomarkers and, second, to maintain clinical remission and reach endoscopic normalisation to prevent long-term disability. Treatments for inducing remission include 5-aminosalicylic acid drugs and corticosteroids. Maintenance treatments include 5-aminosalicylic acid drugs, thiopurines, biologics (eg, anti-cytokines and anti-integrins), and small molecules (Janus kinase inhibitors and sphingosine-1-phosphate receptor modulators). Although the therapeutic options are expanding, 10–20% of patients still require proctocolectomy for medically refractory disease. The keys to breaking through this therapeutic ceiling might be the combination of therapeutics with precision and personalised medicine.
15. Indications
Maintaining remission in UC
Reduce risk of colorectal cancer by 75%
(long term Rx for extensive disease)
Less effective for maintenance in CD
Inducing remission in mild UC/CD (higher
doses)
21. Mesalazine
Available as
Enteric-coated tablets (for ileal Crohn’s disease)
Slow release tablets (for proximal bowel Crohn’s)
Enemas, suppositories (for distal colonic disease)
Used when sulphasalazine can not be
tolerated
22. Sulfasalazine
Oral use
Mesalamine (5-aminosalicylic acid).
Oral delayed release capsules
Enema
Olsalazine.
5-ASA-n=n-5-ASA
Bacterial flora breaks it into 5-ASA
Aminosalicylates
28. Indications
Steroid sparing agents
Active disease CD/UC
Maintenance of remission CD/UC
Generally continue treatment x 3-4years
29. Ciclosporin
MOA:inhibitor of calcineurin
preventing clonal expansion of T
cells
Indicated in Severe UC
No value in CD
30. Methotrexate
MOA: inhibitor of dihyrofolate reductase;
anti-inflammatory
Inducing remission/preventing relapse
in CD
Refractory to or intolerant of
Azathioprine
31. Infliximab
Indicated active and fistulating CD
- in severe CD refractory or intolerant
of steroids & immunosupressants
- for whom surgery is inappropriate
MOA: anti-TNF monoclonal antibody
Potent anti-inflammatory
37. Management of CD
to induce remission
1. oral high dose of 5-ASA
1. +- oral corticosteroids reducing over 8/52
2. Azathioprine
3. iv steroids/ metronidazole/elemental
diet/surgery/infliximab