Ulcerative Colitis: Achieving and Maintaining Remission

Hannah R. Howell, PharmD

Disclosures

US Pharmacist. 2008;33(12):30-38. 

In This Article

Introduction and Overview of UC

Introduction

Ulcerative colitis (UC) is a chronic inflammatory bowel disorder (IBD) characterized by diffuse mucosal inflammation of the colon. It affects between 250,000 and 500,000 Americans.[1] Unlike Crohn's disease, which may affect the entire gastrointestinal (GI) tract, UC is limited to the colon. UC almost always involves the rectum, but may extend proximally in a contiguous fashion to involve portions of, or the entire, colon (Table 1). In the majority of new cases diagnosed, disease is limited to the distal or left side of the colon, and there is some evidence that aggressive pharmacotherapy early in the disease may prevent progression and extension of inflammation.[2] This article will review the initial treatment options for UC and their place in therapy for both acute attacks and maintenance of remission.

Overview of UC

The hallmark symptom of UC is bloody diarrhea. Other symptoms patients may commonly experience include abdominal pain, rectal urgency, and tenesmus. Severity of symptoms will depend on the severity and extent of inflammation. The clinical course is marked by exacerbations and remissions, and about half of patients with UC will experience an exacerbation in any given year. About 15% of patients will have severe attacks involving the entire colon, and colectomy will be required in 30% of these patients.[3] Patients with UC have an increased risk of cancer, depending mainly on both the duration and extent of disease. The American College of Gastroenterology recommends a colonoscopy eight to 10 years after diagnosis and then every one to two years thereafter.[4]

Onset of UC is usually between 15 and 40 years of age, with another peak in incidence after age 60. Men and women are equally affected.[5] The etiology of UC is unknown, but is most likely the result of interactions between genetic, environmental, and microbial factors, as well as the intestinal immune system.

A complete history and examination should be done when UC is suspected. Recent antibiotic use may suggest pseudomembranous colitis; therefore, testing for Clostridium difficile (C. diff) toxin in the stool should always be done to rule out C. diff colitis. Lab tests such as C-reactive protein and erythrocyte sedimentation rate that suggest inflammation may be elevated. Abdominal x-rays are essential to detect major complications that can occur, such as colonic distention that can lead to toxic megacolon or intestinal perforation. They can also help to assess the extent of disease. Colonoscopy or proctosigmoidoscopy and biopsy are the gold standards for diagnosis of UC. Diffuse, continuous changes in the vascular pattern of the colonic mucosa as well as ulcerations and exudates are commonly seen.[3,6]

Once the diagnosis of UC is made, both the extent and severity of disease should be assessed in order to guide treatment (Table 2). The goals of treatment are directed at inducing and then maintaining remission of symptoms and inflammation in order to improve quality of life. About 65% of patients will achieve clinical remission with medical treatment, and 80% of patients who are compliant with treatment will maintain remission.[7] Therefore, it is important to educate patients on the benefits of complying with treatment regimens.

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