Ulcerative Colitis: Achieving and Maintaining Remission

Hannah R. Howell, PharmD

Disclosures

US Pharmacist. 2008;33(12):30-38. 

In This Article

Corticosteroids

Due to their potent anti-inflammatory effects, rectal, oral, and parenteral CCSs are all used for treatment of active UC, and selection depends on both the severity and extent of disease. CCSs have no role in maintenance of remission because of the many adverse effects from prolonged therapy (e.g., increased susceptibility to infections and osteoporosis).[3,23] As with any drug therapy, the benefits of CCSs must be balanced by the risks.

Rectally administered CCSs (i.e., suppositories, foams, enemas) are less effective than rectal 5-ASA, but the combination is often more effective at achieving remission than either treatment alone in patients with active distal colitis. Patients using rectal CCSs on a regular basis may develop systemic adverse effects; therefore, prolonged therapy is not recommended.[2] Budesonide is a potent CCS that has poor bioavailability and extensive first-pass metabolism. It acts topically on the colonic mucosa. When given orally, budesonide is released in the colon and provides therapeutic benefit with less systemic toxicity.[23] Studies have shown conflicting results when oral budesonide was compared to conventional oral CCSs.[2] The exact place of CCSs in therapy is unclear at this time.

Orally administered steroids, such as prednisone, are generally reserved for patients with moderate to severe active UC.[23] They are also indicated for patients who have failed to respond to oral and rectal 5-ASA or rectal CCSs.[3] About one-third of patients will require oral CCS therapy at some time during the course of their disease.[24] The typical dose of oral prednisone is 40 to 60 mg daily, and once a response is achieved (usually 10-14 days), the dose should be tapered gradually over the next eight weeks.[6]

Intravenous CCSs are reserved for hospitalized patients with severe or fulminant-active UC and for those who have failed to respond to oral CCSs. There are no placebo-controlled trials with IV CCSs, but several observational studies have shown a response rate of about 50%.[25] Patients will usually respond within seven to 10 days of IV treatment with the equivalent of methylprednisolone 60 mg daily. Transition to oral CCSs with plans to taper the dose should occur after the initial response.[23]

Long-term therapy with CCSs is not recommended secondary to significant side effects, but many patients will become dependent and experience an increase in disease activity when the dose is reduced. Despite this, even low doses of CCSs are not recommended for maintaining remission.[26] Azathioprine and infliximab can be used to wean most patients off CCSs.

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