• Ulcerative colitis (UC) is an inflammation of the large intestine (colon).
• The cause of ulcerative colitis is unknown.
• Intermittent rectal bleeding, crampy abdominal pain, and diarrhea often are symptoms of ulcerative colitis.
• The diagnosis of ulcerative colitis can be made with a barium enema, but direct visualization (sigmoidoscopy or colonoscopy) is the most accurate means of diagnosis.
• Long-standing ulcerative colitis is a risk factor for colon cancer.Ulcerative colitis also can cause inflammation in joints, spine, skin, eyes, and the liver and its bile ducts.

Ulcerative colitis is considered to be related to Crohn’s disease, another chronic inflammatory disease of the intestines, together, they are frequently referred to as inflammatory bowel disease (IBD).

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Ulcerative colitis is a chronic inflammation of the large intestine (colon). The colon is the part of the digestive system where water is removed from undigested material, and the remaining waste material is stored. The rectum is the end of the colon adjacent to the anus. In patients with ulcerative colitis, ulcers, and inflammation of the inner lining of the colon lead to symptoms of abdominal pain, diarrhea, and rectal bleeding.

Ulcerative colitis and Crohn’s diseases are chronic conditions. Crohn’s disease can affect any portion of the gastrointestinal tract, including all layers of the bowel wall. It may not be limited to the GI tract (affecting the liver, skin, eyes, and joints).

Ulcerative colitis only affects the lining of the colon (large bowel). Men and women are affected equally. The most commonly begin during adolescence and early adulthood, but they also can begin during childhood and later in life.

Ulcerative colitis found worldwide but due to alcoholism, unhealthy/nonorganic and/or artificial food, smoking and stress/anxiety/depression, is most common in the United States, England, and northern Europe. It is especially common in people of Palestine and in Jewish areas.

Ulcerative colitis is rare in the black population, an increased frequency of this condition has been observed recently in developing nations.

First degree relatives of people with ulcerative colitis have an increased lifetime risk of developing the disease, but the overall risk remains small.

Ulcerative colitis illustration

Common symptoms of ulcerative colitis include rectal bleeding, abdominal pain, and diarrhea, but there is a wide range of symptoms among patients with this disease. Variability of symptoms reflects differences in the extent of disease (the amount of the colon and rectum that are inflamed) and the intensity of inflammation. Generally, patients with inflammation confined to the rectum and a short segment of the colon adjacent to the rectum have milder symptoms and a better prognosis than patients with more widespread inflammation of the colon. The different types of ulcerative colitis are classified according to the location and the extent of inflammation:

1. Ulcerative proctitis refers to inflammation that is limited to the rectum. In many patients with ulcerative proctitis, mild intermittent rectal bleeding may be the only symptom. Other patients with more severe rectal inflammation may, in addition, experience rectal pain, urgency (sudden feeling of having to defecate and a need to rush to the bathroom for fear of soiling), and tenesmus (ineffective, painful urge to move one’s bowels caused by the inflammation).
2. Proctosigmoiditis involves inflammation of the rectum and the sigmoid colon (a short segment of the colon contiguous to the rectum). Symptoms of proctosigmoiditis, like that of proctitis, include rectal bleeding, urgency, and tenesmus. Some patients with proctosigmoiditis also develop bloody diarrhea and cramps.
3. Left-sided colitis involves inflammation that starts at the rectum and extends up the left colon (sigmoid colon and descending colon). Symptoms of left-sided colitis include bloody diarrhea, abdominal cramps, weight loss, and left-sided abdominal pain.
4. Pancolitis or universal colitis refers to inflammation affecting the entire colon (right colon, left colon, transverse colon and the rectum). Symptoms of pancolitis include bloody diarrhea, abdominal pain and cramps, weight loss, fatigue, fever, and night sweats. Some patients with pancolitis have low-grade inflammation and mild symptoms that respond readily to medications. Generally, however, patients with pancolitis suffer more severe disease and are more difficult to treat than those with more limited forms of ulcerative colitis.
5. Fulminant colitis is a rare but severe form of pancolitis. Patients with fulminant colitis are extremely ill with dehydration, severe abdominal pain, protracted diarrhea with bleeding, and even shock. They are at risk of developing toxic megacolon (marked dilatation of the colon due to severe inflammation) and colonic rupture (perforation).

Patients with fulminant colitis and toxic megacolon are treated in the hospital with potent intravenous medications. Unless they respond to treatment promptly, surgical removal of the diseased colon is necessary to prevent colonic rupture.

While the intensity of colon inflammation in ulcerative colitis waxes and wanes over time, the location and the extent of disease in a patient generally stays constant. Therefore, when a patient with ulcerative proctitis develops a relapse of his or her disease, the inflammation usually is confined to the rectum. Nevertheless, a small number of patients (less than 10%) with ulcerative proctitis or proctosigmoiditis can later develop more extensive colitis. Thus, patients who initially only have ulcerative proctitis can later develop left-sided colitis or even pancolitis.

Ulcerative colitis involves abnormal activation of the immune system in the intestines (against harmful bacteria, viruses, fungi, and other foreign invaders).

Alcoholism, unhealthy/nonorganic and/or artificial food, smoking and stress/anxiety/depression and the continued abnormal activation of the immune system causes chronic inflammation and ulceration portions of the large intestine.

The diagnosis of ulcerative colitis is suggested by the symptoms of abdominal pain, rectal bleeding, and diarrhea. As there is no gold standard for diagnosis, the ultimate diagnosis relies on a combination of symptoms, the appearance of the colonic lining at the time of endoscopy, histologic features of biopsies of the colonic lining, and studies of stool to exclude the presence of infectious agents that may be causing the inflammation.

• Stool specimens are collected for analysis to exclude infection and parasites, since these conditions can cause colitis that mimics ulcerative colitis.
• Blood tests may show anemia (a low red blood cell count), and an elevated white blood cell count and/or an elevated sedimentation rate (sed rate). An elevated white blood cell count and sed rate both reflect ongoing inflammation that may be associated with infection or with any type of chronic inflammation including ulcerative colitis and Crohn’s disease. Anemia, especially in a young male with chronic pain and diarrhea should raise the clinician’s suspicion for IBD.
• Other blood tests also may be checked including kidney function, liver function tests, iron studies, and C-reactive protein (another sign of inflammation).
• There is some evidence that a stool test for a protein called calprotectin could be useful in identifying patients who would benefit from colonoscopy. Calprotectin seems to be a sensitive marker of intestinal inflammation meaning that it can be elevated before symptoms become severe and the signs of inflammation are unclear. In the right setting, particularly early in the course of IBD, elevated levels can suggest inflammatory bowel disease. This test alone, however, cannot distinguish between different diseases causing the inflammation so should be used with caution.
• Confirmation of ulcerative colitis requires a test to visualize the large intestine colonoscope.  Direct visualization of the inside of the colon to establish the diagnosis and to determine the extent of the colitis. Small tissue samples (biopsies) can be obtained during the procedure to determine the severity of the colitis.
• A barium enema X-ray also may indicate the diagnosis of ulcerative colitis. During a barium enema, a chalky liquid substance is administered into the rectum and injected into the colon. Barium is so dense that X-rays do not pass through it so the outline of the colon can be seen on X-ray pictures. A barium enema is less accurate and useful than direct visualization (sigmoidoscopy or colonoscopy) in the diagnosis of Ulcerative colitis. If a barium enema is performed and ulcerative colitis is suspected, a colonoscopy is needed to verify the diagnosis.

Some newer diagnostic modalities include video capsule endoscopy and CT/MRI enterography. Video capsule endoscopy (VCE) might be useful for detection of small bowel disease in patients with a diagnosis of Ulcerative colitis with atypical features and who might be suspected of actually having Crohn’s disease. With VCE, patients swallow a capsule that contains a camera that takes pictures while it travels through the intestines and sends the pictures wirelessly to a recorder. The pictures are then reviewed. In a study in 2007, VCE confirmed the presence of small bowel disease in about 15% of patients with ulcerative colitis with atypical features or unclassified inflammatory bowel disease, thus changing the diagnosis to Crohn’s disease (which is not limited to the large bowel as in UC). This might be a useful diagnostic modality in this specific patient population.

CT and MRI enterography are imaging techniques which use oral liquid contrast agents consisting of PEG solutions or low concentration of barium to provide more adequate distension of the colon and small intestine. These have been reported to be superior to standard imaging techniques in the evaluation of small bowel pathology in patients with Crohn’s disease. They have also been shown to provide adequate estimations of disease severity in ulcerative colitis (with some under- and overestimations).

Blood transfusions, pancolitis, and toxic megacolon

Patients with ulcerative colitis limited to the rectum (proctitis) or colitis limited to the end of the left colon (proctosigmoiditis) usually do quite well. Brief periodic treatments using oral medications or enemas may be sufficient. Serious complications are rare in these patients. In those with more extensive disease, blood loss from the inflamed intestines can lead to anemia and may require treatment with iron supplements or even blood transfusions (I {Dr Qaisar Ahmed} don’t recommend).

Rarely, the colon can acutely dilate to a large size when the inflammation becomes very severe. This condition is called toxic megacolon. Patients with toxic megacolon are extremely ill with fever, abdominal pain and distention, dehydration, and malnutrition. Unless the patient improves rapidly with medication especially Homeopathic medication, with allopathic treatment surgery usually is necessary to prevent colonic rupture.

Cancers

Colon cancer is a recognized complication of chronic ulcerative colitis. The risk for cancer begins to rise after eight to ten years of colitis. Patients with only ulcerative proctitis probably do not have increased risk of colon cancer compared to the general population. Among patients with active pancolitis (involving the entire colon) for 10 years or longer, the risk of colon cancer is increased compared to the general population. In patients with colitis limited to the left side of the colon, the risk of colon cancer is increased but not as high as in patients with chronic pancolitis.

Since these cancers have a more favorable outcome when diagnosed and treated at an earlier stage, yearly colon examinations may be recommended after eight years of known extensive disease. During these examinations, samples of tissue (biopsies) can be taken to search for precancerous changes in the lining cells of the colon. When precancerous changes are found, removal of the colon may be necessary to prevent colon cancer.

Other complications of ulcerative colitis

Complications of ulcerative colitis can involve other parts of the body.

• Ten percent of the patients can develop inflammation of the joints (arthritis).
• Some patients have low back pain due to arthritis of the sacroiliac joints.
• Ankylosing spondylitis (AS) is a type of arthritis that affects the vertebral joints of affected individuals. There seems to be an increased incidence of ankylosing spondylitis among patients with inflammatory bowel disease.
• Rarely, patients may develop painful, red, skin nodules (erythema nodosum). Others can have painful, red eyes (uveitis, episcleritis). Because these particular complications can risk permanent vision impairment, eye pain or redness are symptoms that require a physician’s evaluation.
• Diseases of the liver and bile ducts also may be associated with ulcerative colitis. For example, in patients with a rare condition called sclerosing cholangitis, repeated infections and inflammation in the bile ducts can lead to recurrent fever, yellowing of skin (jaundice), cirrhosis, and the need for a transplantation of the liver.
• Finally, patients with ulcerative colitis also might have an increased tendency to form blood clots, especially in the setting of active disease.

In allopathy both drugs and surgery have been used to treat ulcerative colitis. However, surgery is reserved for those with severe inflammation and life-threatening complications. There is no allopathic drug that can cure ulcerative colitis (for Homeopathic treatment see lower part of article please).

With allopathic treatment patients with ulcerative colitis will typically experience periods of relapse (worsening of inflammation) followed by periods of remission (resolution of inflammation) lasting months to years. During relapses, symptoms of abdominal pain, diarrhea, and rectal bleeding worsen. During remissions, these symptoms subside.

Since ulcerative colitis cannot be cured by allopathic drugs, the goals of allopathic treatment with drugs are to…

1) induce remissions (⇐click to watch surgery for Ulcerative colitis)

2) maintain remissions

3) minimize side effects of treatment

4) improve the quality of life

5) minimize risk of cancer.

Treatment of ulcerative colitis with allopathic drugs is similar, though not always identical, to treatment of Crohn’s disease.

Drugs for treating ulcerative colitis include

1) Anti-inflammatory agents such as 5-ASA compounds, systemic corticosteroids, topical corticosteroids

2) Immunomodulators.

Anti-inflammatory drugs that decrease intestinal inflammation are analogous to arthritis medications that decrease joint inflammation (arthritis). The anti-inflammatory drugs that are used in the allopathic treatment of ulcerative colitis are:

• Topical 5-ASA compounds such as sulfasalazine (Azulfidine), olsalazine (Dipentum), and mesalamine (Pentasa, Asacol, Lialda, Apriso Rowasa enema) that need direct contact with the inflamed tissue in order to be effective.
• Systemic anti-inflammatory medications such as corticosteroids that decrease inflammation throughout the body without direct contact with the inflamed tissue. Systemic corticosteroids have predictable side effects with long term use.

Immunomodulators are drugs that suppress the body’s immune system either by reducing the cells that are responsible for immunity, or by interfering with proteins that are important in promoting inflammation. Immunomodulators increasingly are becoming important treatments for patients with severe ulcerative colitis who do not respond adequately to anti-inflammatory agents. Examples of immunomodulators include 6-mercaptopurine (6 MP), azathioprine (Imuran), methotrexate (Rheumatrex, Trexall), cyclosporine (Gengraf, Neoral).

It has long been observed that the risk of ulcerative colitis appears to be higher in nonsmokers and in ex-smokers. In certain circumstances, patients improve when treated with nicotine (Homeopathically)

5-ASA (5-aminosalicylic acid), also called mesalamine, is chemically similar to aspirin. Aspirin (acetylsalicylic acid) has been used for many years in treating arthritis, bursitis, and tendinitis (conditions of tissue inflammation). Aspirin, however, is not effective in treating ulcerative colitis. On the other hand, 5-ASA can be effective in treating ulcerative colitis if the drug can be delivered directly (topically) onto the inflamed colon lining. For example, Rowasa enema is a 5-ASA solution that is effective in treating inflammation in and near the rectum (ulcerative proctitis and ulcerative proctosigmoiditis). However, the enema solution cannot reach high enough to treat inflammation in the upper colon. Therefore, for most patients with ulcerative colitis, 5-ASA must be taken orally. When pure 5-ASA is taken orally, however, the stomach and upper small intestine absorb most of the drug before it reaches the colon. Therefore, to be effective as an oral agent for ulcerative colitis, 5-ASA has to be modified chemically to escape absorption by the stomach and the upper intestines. These modified 5-ASA compounds are sulfasalazine (Azulfidine), mesalamine (Pentasa, Rowasa, Asacol, Lialda, Apriso), and olsalazine (Dipentum).

Azulfidine

Sulfasalazine (Azulfidine) has been used successfully for many years in inducing remission among patients with mild to moderate ulcerative colitis. Inducing remission means decreasing intestinal inflammation and relieving symptoms of abdominal pain, diarrhea, and rectal bleeding. Sulfasalazine has also been used for prolonged periods of time to maintain remissions.

Sulfasalazine consists of a 5-ASA molecule linked chemically to a sulfapyridine molecule. (Sulfapyridine is a sulfa antibiotic). Connecting the two molecules together prevents absorption by the stomach and the upper intestines prior to reaching the colon. When sulfasalazine reaches the colon, the bacteria in the colon will break the linkage between the two molecules. After breaking away from 5-ASA, sulfapyridine is absorbed into the body and then excreted in the urine. Most of the active 5-ASA drug, however, remains in the colon to treat colitis.

Most of the side effects of sulfasalazine are due to the sulfapyridine molecule. These side effects include nausea, heartburn, headache, anemia, skin rashes, and, in rare instances, hepatitis and kidney inflammation.

In men, sulfasalazine can reduce the sperm count. The reduction in sperm count is reversible, and the count usually returns to normal after discontinuing sulfasalazine or by changing to a different 5- ASA compound.

The benefits of sulfasalazine generally are dose related. Therefore, high doses of sulfasalazine may be necessary to induce remission. Some patients cannot tolerate high doses because of nausea and stomach upset. To minimize stomach upset, sulfasalazine generally is taken after or with meals. Some patients find it easier to take Azulfidine-EN (enteric-coated form of sulfasalazine). Enteric-coating helps decrease stomach upset. The newer 5-ASA compounds do not have the sulfapyridine component and have fewer side effects than sulfasalazine.

Asacol

Asacol is a tablet consisting of the 5-ASA compound, mesalamine, surrounded by an acrylic resin coating. (Asacol is sulfa free.) The resin coating prevents the 5-ASA from being absorbed as it passes through the stomach and the small intestine. When the tablet reaches the terminal ileum and the colon, the resin coating dissolves, thus releasing 5-ASA into the colon.

Asacol is effective in inducing remissions in patients with mild to moderate ulcerative colitis. It also is effective when used for prolonged periods of time to maintain remissions. The recommended dose of Asacol to induce remission is two 400-mg tablets three times daily (total of 2.4 grams a day). Two tablets of Asacol twice daily (1.6 grams a day) is recommended for maintaining remission. Occasionally, the maintenance dose is higher.

As with Azulfidine, the benefits of Asacol are dose-related. If patients do not respond to 2.4 grams a day of Asacol, the dose frequently is increased to 3.6 grams a day (and sometimes even higher) to induce remission. If patients fail to respond to the higher doses of Asacol, then alternatives, such as corticosteroids, are considered.

Lialda

Lialda (mesalamine multi matrix, MMX) is an extended release formulation. It is a 5-ASA medication within an inert matrix that is surrounded by a coating. When the capsule reaches the distal ileum, the outer coating (the capsule) dissolves. The intestinal fluid then is absorbed into the matrix forming a gel-like substance which prolongs the contact of the medication with the colonic wall as the mesalamine slowly separates from the matrix. This extended release formulation allows for higher doses to be taken less frequently throughout the day and might and improve compliance.

The most common side effects experienced while taking Lialda are flatulence, abdominal pain, headache, nausea, and dyspepsia.

Apriso

Apriso is another formulation of 5-ASA that consists of extended-release mesalamine granules encased in microcrystalline cellulose within a capsule. Dissolution of the capsule occurs in the distal ileum, and, since the granules are encased in the cellulose and only slowly separates from the cellulose, there is prolonged delivery of medication as the cellulose and mesalamine travel through the colon.

The most common side effects of this medication are headache, diarrhea, abdominal pain, nausea, nasopharyngitis, influenza-like illness, and sinusitis.

Pentasa

Pentasa is a capsule consisting of the 5-ASA compound mesalamine inside controlled-release spheres. Like Asacol, it is sulfa free. As the capsule travels down the intestines, the 5-ASA inside the spheres is slowly released into the intestines. Unlike Asacol, the mesalamine in Pentasa is released into the small intestine as well as the colon. Therefore, Pentasa can be effective in treating inflammation in the small intestine and the colon. Pentasa is currently the most logical 5-ASA compound for treating mild to moderate Crohn’s disease involving the small intestine. Pentasa also is used to induce remission and maintain remission among patients with mild to moderate ulcerative colitis.

Olsalazine (Dipentum)

Olsalazine (Dipentum) consists of two 5-ASA molecules linked together. It is sulfa-free. The linked 5-ASA molecules travel through the stomach and the small intestine unabsorbed. When the drug reaches the terminal ileum and the colon, the normal bacteria in the intestine break the linkage and release the active drug into the colon and the terminal ileum. Olsalazine has been used in treating ulcerative colitis and in maintaining remissions. A side effect unique to olsalazine is secretory diarrhea (diarrhea resulting from excessive production of fluid in the intestines). This condition occurs in some patients, and diarrhea sometimes can be severe.

Balsalazide (Colazal)

Balsalazide (Colazal) is a capsule in which the 5-ASA is linked by a chemical bond to another molecule that is inert (without effect on the intestine) and prevents the 5-ASA from being absorbed. This drug is able to travel through the intestine unchanged until it reaches the end of the small bowel (terminal ileum) and colon. There, intestinal bacteria break apart the 5-ASA and the inert molecule, releasing the 5-ASA. Because intestinal bacteria are most abundant in the terminal ileum and colon, Colazal is used to treat inflammation predominantly localized to the colon.

More clinical trials are needed to compare the effectiveness of Colazal to the other mesalamine compounds such as Asacol in treating ulcerative colitis. Therefore in the United States, choosing which 5-ASA compound has to be individualized. Some doctors prescribe Colazal for patients who cannot tolerate or fail to respond to Asacol. Others prescribe Colazal for patients with predominantly left-sided colitis since some studies seem to indicate that Colazal is effective in treating left-sided colitis.

Side Effects of 5-ASA Compounds

The sulfa-free 5-ASA compounds have fewer side effects than sulfasalazine and also do not impair male fertility. In general, they are safe medications for long-term use and are well-tolerated.

Patients allergic to aspirin should avoid 5-ASA compounds because they are chemically similar to aspirin.

Rare kidney inflammation has been reported with the use of 5-ASA compounds. These compounds should be used with caution in patients with known kidney disease. It also is recommended that blood tests of kidney function be obtained before starting and periodically during treatment.

Rare instances of acute worsening of diarrhea, cramps, and abdominal pain may occur which at times may be accompanied by fever, rash, and malaise. This reaction is believed to represent an allergy to the 5-ASA compound.

Rowasa Enema

Rowasa is the 5-ASA compound mesalamine in enema form and is effective in ulcerative proctitis and ulcerative proctosigmoiditis (two conditions where active 5-ASA drugs taken as enemas can easily reach the inflamed tissues directly). Each Rowasa enema contains 4 grams of mesalamine in 60 cc of fluid. The enema usually is administered at bedtime, and patients are encouraged to retain the enema through the night.

The enema contains sulfite and should not be used by patients with sulfite allergies. Otherwise, Rowasa enemas are safe and well-tolerated.

Rowasa also comes in suppository form for treating limited proctitis. Each suppository contains 500 mg of mesalamine and usually is administered twice daily.

While some patients improve within several days of starting Rowasa, the usual course of treatment is three to six weeks. Some patients may need even longer courses of treatment for optimal benefit. In patients who do not respond to Rowasa, oral 5-ASA compounds (such as Asacol) can be added. Some studies have reported increased effectiveness in treating ulcerative proctitis and proctosigmoiditis by combining oral 5-ASA compounds with Rowasa enemas. Oral 5-ASA compounds also are used to maintain remission in ulcerative proctitis and proctosigmoiditis.

Another alternative for patients who fail to respond to Rowasa or who cannot use Rowasa is cortisone enemas (Cortenema). Cortisone is a potent anti-inflammatory agent. Oral corticosteroids are systemic drugs with serious and predictable long-term side effects. Cortenema is a topical corticosteroid that has less absorption into the body than oral corticosteroids, and, therefore, it has fewer and less severe side effects.

Corticosteroids (Prednisone, prednisolone, hydrocortisone, etc.) have been used for many years in the treatment of patients with moderate to severe Crohn’s disease and ulcerative colitis or who fail to respond to optimal doses of 5-ASA compounds. Unlike the 5-ASA compounds, corticosteroids do not require direct contact with the inflamed intestinal tissues to be effective. Oral corticosteroids are potent anti-inflammatory agents. After absorption, corticosteroids exert prompt anti-inflammatory action throughout the body. Consequently, they are used in treating Crohn’s enteritis, ileitis, and ileocolitis, as well as ulcerative and Crohn’s colitis. In critically ill patients, intravenous corticosteroids (such as hydrocortisone) can be given in the hospital.

Corticosteroids are faster acting than the 5-ASA compounds. Patients frequently experience improvement in their symptoms within days of starting corticosteroids. Corticosteroids, however, do not appear to be useful in maintaining remissions in ulcerative colitis.

Corticosteroid side effects

Side effects of corticosteroids depend on the dose and duration of use. Short courses of prednisone, for example, usually are well tolerated with few and mild side effects. Long term, high doses of corticosteroids usually produce predictable and potentially serious side effects. Common side effects include rounding of the face (moon face), acne, increased body hair, diabetes, weight gain, high blood pressure, cataracts, glaucoma, increased susceptibility to infections, muscle weakness, depression, insomnia, mood swings, personality changes, irritability, and thinning of the bones (osteoporosis) with an accompanying increased risk of compression fractures of the spine. Children on corticosteroids can experience stunted growth.

The most serious complication from long-term corticosteroid use is aseptic necrosis of the hip joints. Aseptic necrosis means the death of bone tissue. It is a painful condition that can ultimately lead to the need for surgical replacement of the hips. Aseptic necrosis also has been reported in knee joints. It is unknown how corticosteroids cause aseptic necrosis. Patients on corticosteroids who develop pain in the hips or knees should report the pain to their doctors promptly. Early diagnosis of aseptic necrosis with cessation of corticosteroids has been reported in some patients to decrease the severity of the condition and possibly help avoid hip replacement.

Prolonged use of corticosteroids can depress the ability of the body’s adrenal glands to produce cortisol (a natural corticosteroid necessary for the proper functioning of the body). Abruptly discontinuing corticosteroids can cause symptoms due to a lack of natural cortisol (a condition called adrenal insufficiency). Symptoms of adrenal insufficiency include nausea, vomiting, and even shock. Withdrawing corticosteroids too quickly also can produce symptoms of joint aches, fever, and malaise. Therefore, corticosteroids need to be gradually reduced rather than abruptly stopped.

Even after the corticosteroids are discontinued, the adrenal glands’ ability to produce cortisol can remain depressed for months to two years. The depressed adrenal glands may not be able to produce enough cortisol to help the body handle stress such as accidents, surgery, and infections. These patients will need treatment with corticosteroids (prednisone, hydrocortisone, etc.) during stressful situations to avoid developing adrenal insufficiency.

Because corticosteroids are not useful in maintaining remission in ulcerative colitis and Crohn’s disease and because they have predictable and potentially serious side effects, these drugs should be used for the shortest possible length of time.

Preventing Corticosteroid-induced Osteoporosis

Long-term use of corticosteroids such as prednisolone or prednisone can cause osteoporosis . Corticosteroids cause decreased calcium absorption from the intestines and increased loss of calcium from the kidneys and bones. Increasing dietary calcium intake is important but alone cannot halt corticosteroid-induced bone loss. Management of patients on long term corticosteroids should include:

• Adequate calcium (1000 mg daily if premenopausal, 1500 mg daily if postmenopausal) and vitamin D (800 units daily) intake.
• Periodic review with the doctor on the need for continued corticosteroid treatment and the lowest effective dose if continued treatment is necessary.
• A bone density study to measure the extent of bone loss in patients taking corticosteroids for more than three months.
• Regular weight-bearing exercise, and stop smoking cigarettes.
• Discussion with the doctor regarding the use of alendronate (Fosamax) or risedronate (Actonel) in the prevention and the treatment of corticosteroid-induced osteoporosis.

Immunomodulators are medications that weaken the body’s immune system (I – Dr. Qaisar Ahmed never adise it). The immune system is composed of immune cells and the proteins that these cells produce. These cells and proteins serve to defend the body against harmful bacteria, viruses, fungi, and other foreign invaders. Activation of the immune system causes inflammation within the tissues where the activation occurs. (Inflammation is, in fact, an important mechanism to defend the body used by the immune system).

Normally, the immune system is activated only when the body is exposed to harmful invaders. In patients with Crohn’s disease and ulcerative colitis, however, the immune system is abnormally and chronically activated in the absence of any known invader. Immunomodulators decrease tissue inflammation by reducing the population of immune cells and/or by interfering with their production of proteins that promote immune activation and inflammation. Generally, the benefits of controlling moderate to severe ulcerative colitis outweigh the risks of infection due to weakened immunity. Examples of immunomodulators include azathioprine (Imuran), 6-mercaptopurine (6-MP, Purinethol), cyclosporine (Sandimmune), and methotrexate (Rheumatrex, Trexall).

Azathioprine (Imuran) and 6-MP (Purinethol)

Azathioprine and 6-mercaptopurine (6-MP) are medications that weaken the body’s immunity by reducing the population of a class of immune cells called lymphocytes. Azathioprine and 6-MP are related chemically. Specifically, azathioprine is converted into 6-MP inside the body. In high doses, these two drugs have been useful in preventing the rejection of transplanted organs and in treating leukemia. In low doses, they have been used for many years to treat patients with moderate to severe Crohn’s disease and ulcerative colitis.

Azathioprine and 6-MP are increasingly recognized by doctors as valuable drugs in treating Crohn’s disease and ulcerative colitis. Some 70% of patients with moderate to severe disease will benefit from these drugs. Because of the slow onset of action and the potential for side effects, however, 6-MP and azathioprine are used mainly in the following situations:

• Patients with ulcerative colitis and Crohn’s disease not responding to corticosteroids.
• Patients who are experiencing undesirable corticosteroid-related side effects.
• Patients who are dependent on corticosteroids and are unable to discontinue them without developing relapses.

When azathioprine and 6-MP are added to corticosteroids in the treatment of ulcerative colitis patients who do not respond to corticosteroids alone, there may be an improved response or smaller doses and shorter courses of corticosteroids may be effective. Some patients can discontinue corticosteroids altogether without experiencing relapses. The ability to reduce corticosteroid requirements has earned 6-MP and azathioprine their reputation as “steroid-sparing” medications.

In patients with severe ulcerative colitis who suffer frequent relapses, 5-ASA may not be sufficient, and more potent azathioprine and 6-MP will be necessary to maintain remissions. In the doses used for treating ulcerative colitis and Crohn’s disease, the long-term side effects of azathioprine and 6-MP are less serious than long-term oral corticosteroids or repeated courses of oral corticosteroids.

Side Effects of 6-MP and Azathioprine

Side effects of 6-MP and azathioprine include increased vulnerability to infections, inflammation of the liver (hepatitis) and pancreas, (pancreatitis), and bone marrow toxicity (interfering with the formation of cells that circulate in the blood).

The goal of treatment with 6-MP and azathioprine is to weaken the body’s immune system in order to decrease the intensity of inflammation in the intestines; however, weakening the immune system increases the patient’s vulnerability to infections. For example, in a group of patients with severe Crohn’s disease unresponsive to standard doses of azathioprine, raising the dose of azathioprine helped to control the disease, but two patients developed cytomegalovirus (CMV) infection. CMV usually infects individuals with weakened immune systems such as patients with AIDS or cancer, especially if they are receiving chemotherapy, which further weakens the immune system.

Azathioprine and 6-MP-induced inflammation of the liver (hepatitis) and pancreas (pancreatitis) are rare. Pancreatitis typically causes severe abdominal pain and sometimes vomiting. Pancreatitis due to 6-MP or azathioprine occurs in a small percentage of patients, usually during the first several weeks of treatment. Patients who develop pancreatitis should not receive either of these two medications again.

Azathioprine and 6-MP also suppress the bone marrow. The bone marrow is where red blood cells, white blood cells, and platelets are made. Actually, a slight reduction in the white blood cell count during treatment is desirable since it indicates that the dose of 6-MP or azathioprine is high enough to have an effect; however, excessively low red or white blood cell counts indicates bone marrow toxicity. Therefore, patients on 6-MP and azathioprine should have periodic blood counts (usually every two weeks initially and then every 3 months during maintenance) to monitor the effect of the drugs on their bone marrow.

6-MP can reduce the sperm count in men. When the partners of male patients on 6-MP conceive, there is a higher incidence of miscarriages and vaginal bleeding. There also are respiratory difficulties in the newborn. Therefore, it is recommended that whenever feasible, male patients should stop 6-MP and azathioprine for three months before attempting to conceive.

Patients on long-term, high dose azathioprine to prevent rejection of the kidney after kidney transplantation have an increased risk of developing lymphoma, a malignant disease of lymphatic cells. There is no evidence at present that long term use of azathioprine and 6-MP in the low doses used in IBD increases the risk for lymphoma, leukemia or other malignancies.

Other Issues in the Use of 6-MP

One problem with 6-MP and azathioprine is their slow onset of action. Typically, full benefit of these drugs is not realized for three months or longer. During this time, corticosteroids frequently have to be maintained at high levels to control inflammation.

The reason for this slow onset of action is partly due to the way doctors prescribe 6-MP. Typically, 6-MP is started at a dose of 50 mg daily. The blood count is then checked two weeks later. If the white blood cell count (specifically the lymphocyte count) is not reduced, the dose is increased. This cautious, stepwise approach helps prevent severe bone marrow and liver toxicity, but also delays benefit from the drug.

Studies have shown that giving higher doses of 6-MP early can speed up the benefit of 6-MP without increased toxicity in most patients, but some patients do develop severe bone marrow toxicity. Therefore, the dose of 6-MP has to be individualized. Scientists now believe that an individual’s vulnerability to 6-MP toxicity is genetically inherited. Blood tests can be performed to identify those individuals with increased vulnerability to 6-MP toxicity. In these individuals, lower initial doses can be used. Blood tests can also be performed to measure the levels of certain by-products of 6-MP. The levels of these by-products in the blood help doctors more quickly determine whether the dose of 6-MP is right for the patient.

6-MP metabolite levels

In addition to monitoring blood cell counts and liver tests, doctors also may measure blood levels of the chemicals that are formed from 6-MP (6-MP metabolites), which can be helpful in several situations such as:

1. If a patient’s disease is not responding to standard doses of 6-MP or azathioprine and his/her 6-MP blood metabolite levels are low, compliance should be checked, and if satisfactory, the dose of 6-MP or azathioprine may be increased.
2. If a patient’s disease does not respond to treatment and his/her 6-MP blood metabolite levels are very low, it is most likely that he/she is not taking his/her medication. The lack of response in this case is due to patient non-compliance.

How Long Can Patients Continue on 6-MP?

Patients have been maintained on 6-MP or azathioprine for years without any important long-term side effects. Their doctors, however, should closely monitor their patients on long-term 6-MP. There is data suggesting that patients on long-term maintenance with 6-MP or azathioprine fare better than those who stop these medications. Those who stop 6-MP or azathioprine are more likely to experience relapses, more likely to need corticosteroids or undergo surgery.

Methotrexate

Methotrexate (Rheumatrex, Trexall) is an immunomodulator and anti-inflammatory medication. Methotrexate has been used for many years in the treatment of severe rheumatoid arthritis and psoriasis. It has been helpful in treating patients with moderate to severe Crohn’s disease who are either not responding to 6-MP and azathioprine or are intolerant of these two medications. Methotrexate also may be effective in patients with moderate to severe ulcerative colitis who are not responding to corticosteroids or 6-MP and azathioprine. It can be given orally or by weekly injections under the skin or into the muscles. It is more reliably absorbed with the injections.

One major complication of methotrexate is the development of liver cirrhosis when the medication is given over a prolonged period of time (years). The risk of liver damage is higher in patients who also abuse alcohol or have morbid (severe) obesity. Generally, periodic liver biopsies are recommended for a patient who has received a cumulative (total) methotrexate dose of 1.5 grams and higher.

Other side effects of methotrexate include low white blood cell counts and inflammation of the lungs.

Methotrexate should not be used in pregnancy.

Cyclosporine

Cyclosporine (Sandimmune) is a potent immunosuppressant used in preventing organ rejection after transplantation, for example, of the liver. It also has been used to treat patients with severe ulcerative colitis and Crohn’s disease. Because of the approval of infliximab (Remicade) for treating severe Crohn’s disease, cyclosporine probably will be used primarily in severe ulcerative colitis. Cyclosporine is useful in fulminant ulcerative colitis and in severely ill patients who are not responding to systemic corticosteroids. Administered intravenously, cyclosporine can be very effective in rapidly controlling severe colitis and avoiding or delaying surgery.

Cyclosporine also is available as an oral medication, but the relapse rate with oral cyclosporine is high. Therefore, cyclosporine seems most useful when administered intravenously in acute situations.

Side effects of cyclosporine include high blood pressure, impairment of kidney function, and tingling sensations in the extremities. More serious side effects include anaphylactic shock and seizures.

Infliximab (Remicade)

Infliximab (Remicade) is an antibody that attaches to a protein called tumor necrosis factor-alpha (TNF-alpha). TNF-alpha is one of the proteins produced by immune cells during activation of the immune system. TNF-alpha, in turn, stimulates other cells of the immune system to produce and release other proteins that promote inflammation. In Crohn’s disease and in ulcerative colitis, there is continued production of TNF-alpha as part of the immune activation. Infliximab, by attaching to TNF-alpha, blocks its activity and in so doing decreases the inflammation.

Infliximab, an antibody to TNF-alpha, is produced by the immune system of mice after the mice are injected with human TNF-alpha. The mouse antibody then is modified to make it look more like a human antibody, and this modified antibody is infliximab. Such modifications are necessary to decrease the likelihood of allergic reactions when the antibody is administered to humans. Infliximab is given by intravenous infusion over two hours. Patients are monitored throughout the infusion for side effects.

Infliximab has been used effectively for many years for the treatment of moderate to severe Crohn’s disease that was not responding to corticosteroids or immuno-modulators. In Crohn’s disease patients, a majority experienced improvement in their disease after one infusion of infliximab. Some patients noticed improvement in symptoms within days of the infusion. Most patients experienced improvement within two weeks. In patients who respond to infliximab, the improvements in symptoms can be dramatic. Moreover, there can be impressively rapid healing of the ulcers and the inflammation in the intestines after just one infusion.

Only over the last few years infliximab also has been used to treat severe UCs. In a study of over 700 patients with moderate to severe UC, for example, infliximab was found to be more effective than placebo in inducing and maintaining remission.

Infliximab is typically given to induce remission in three doses – at time zero and then two weeks and four weeks later. After remission is attained, maintenance doses can be given every other month.

Side effects of infliximab

Infliximab, generally, is well tolerated. There have been rare reports of side effects during infusions, including chest pain, shortness of breath, and nausea. These effects usually resolve spontaneously within minutes if the infusion is stopped. Other commonly reported side effects include headache and upper respiratory tract infection.

Infliximab, like immuno-modulators, increases the risk for infection. One case of salmonella colitis and several cases of pneumonia have been reported with the use of infliximab. There also have been cases of tuberculosis (TB) reported after the use of infliximab.

Because infliximab is partly a mouse protein, it may induce an immune reaction when given to humans, especially with repeated infusions. In addition to the side effects that occur while the infusion is being given, patients also may develop a “delayed allergic reaction” that occurs 7-10 days after receiving the infliximab. This type of reaction may cause flu-like symptoms with fever, joint pain and swelling, and a worsening of Crohn’s disease symptoms. It can be serious, and if it occurs, a physician should be contacted. Paradoxically, those patients who have more frequent infusions of Remicade are less likely to develop this type of delayed reaction compared to those patients who receive infusions separated by long intervals (6-12 months).

There are some reports of worsening heart disease in patients who have received Remicade. The precise mechanism and role of infliximab in the development of this side effect is unclear. As a precaution, individuals with heart disease should inform their physician of this condition before receiving infliximab.

There have been rare reports of nerve damage such as optic neuritis (inflammation of the nerve of the eye) and motor neuropathy (damage to the nerves controlling muscles).

There have also been rare reports of patients developing viral colitis (cytomegalovirus and herpes simplex virus) while on immunosuppressive medications. These viral infections can mimic a flare of ulcerative colitis and mistakenly suggest resistance to therapy. Before increasing the dose or changing the medication being used to treat the ulcerative colitis, patients should have a thorough evaluation including flexible sigmoidoscopy or limited colonoscopy with biopsies to help make the diagnosis of viral colitis.

Other biological (natural) therapies under development

Adalimumab

Adalimumab is an anti-TNF drug similar to infliximab. It decreases inflammation by blocking tumor necrosis factor (TNF-alpha). In contrast to infliximab, adalimumab is a fully humanized anti-TNF antibody containing no mouse protein and, therefore, might cause less of an immune reaction. Adalimumab is administered subcutaneously (under the skin) instead of intravenously as in the case of infliximab.

Rheumatologists have been using adalimumab for treating inflammation of the joints in patients with rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. It was also approved by the FDA in 2007 for the treatment of moderately to severely active Crohn’s disease. Though not approved formally by the FDA for treatment of ulcerative colitis, a few studies have shown it to have some efficacy in treating patients with ulcerative colitis who are refractory to or have lost their response to infliximab. More information will be required before recommending this as a standard therapy.

Visilizumab (anti-CD3 antibody)

Visilizumab is a humanized antibody that specifically binds to human CD3 expressing T cells, that inhibits the activity of the cells. (CD3 expressing T cells are part of the immune system and seem to play an important role in promoting the inflammation of ulcerative colitis.). In a phase 1 open-label study evaluating the safety and tolerability of this medication, 32 subjects received visilizumab. Results showed that 84% of these patients achieved a clinical response by day 30, 41% achieved clinical remission, and 44% achieved endoscopic remission. The main side effects were decreased CD4 counts and cytokine release syndromes (flu-like symptoms, etc.), though there were no serious infections. Initial data seems promising though more must be learned about this medication before it can be used routinely. This medication is not yet approved by the FDA for the treatment of ulcerative colitis.

Alpha-4 integrin blockade

Alpha-4 integrins on the surface of cells of the immune system help the cells to leave the blood and travel into the tissues where they promote inflammation. Antibodies against these integrins have been developed, to dampen the inflammatory response. Natalizumab is one such agent, and in small studies in patients with ulcerative colitis has been shown to have some efficacy in leading to clinical remission. Another more gut-selective humanized antibody (MLN02) has been evaluated in multi-center trials and has also been found to lead to clinical and endoscopic remission in more patients than placebo. More studies must be conducted to evaluate long term effectiveness and side effects of these medications. This medication is not yet approved by the FDA for treatment of ulcerative colitis.

Homeopathic Treatment

Surgery for ulcerative colitis usually involves removing the entire colon and the rectum. Removal of the colon and rectum is the only permanent cure for ulcerative colitis. This procedure also eliminates the risk of developing colon cancer. Surgery in ulcerative colitis is reserved for the following patients:

1. Patients with fulminant colitis and toxic megacolon who are not responding readily to medications.
2. Patients with long standing pancolitis or left-sided colitis who are at risk of developing colon cancers. Removal of the colon is important when changes are detected in the colon lining.
3. Patients who have had years of severe colitis which has responded poorly to medications.

Standard surgery involves the removal of the entire colon, including the rectum. A small opening is made in the abdominal wall and the end of the small intestine is attached to the skin of the abdomen to form an ileostomy. Stool collects in a bag that is attached over the ileostomy. Recent improvements in the construction of ileostomies have allowed for continent ileostomies. A continent ileostomy is a pouch created from the intestine. The pouch serves as a reservoir similar to a rectum, and is emptied on a regular basis with a small tube. Patients with continent ileostomies do not need to wear collecting bags.

More recently, a surgery has been developed which allows stool to be passed normally through the anus. In an ileo-anal anastomosis, the large intestine is removed and the small intestine is attached just above the anus. Only the diseased lining of the anus is removed and the muscles of the anus remain intact. In this “pull-through” procedure, the normal route of stool elimination is maintained. This procedure has a relatively good success rate, although pouchitis (inflammation of the distal ileum now acting as the rectum) is a well known complication (that should be confirmed by endoscopy) that is manifested by increased diarrhea, urgency, bleeding, and pain.

 Dr Sayyad Qaisar Ahmed (MD {Ukraine}, DHMS) ; senior research officer Dnepropetrovsk state medical academy Ukraine; is a leading Homeopathic physician practicing in Al-Haytham clinic, Umer Farooq Chowk Risalpur Sadder (0923631023, 03119884588), K.P.K, Pakistan.

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