Aminosalicylates, also known as 5-ASAs, are medicines that help to reduce inflammation. This in turn allows damaged tissue to heal.
They're usually the first treatment option for mild or moderate ulcerative colitis.
5-ASAs can be used as a short-term treatment for flare-ups. They can also be taken long term, usually for the rest of your life, to maintain remission.
5-ASAs can be taken:
- orally – by swallowing a tablet or capsule
- as a suppository – a capsule that you insert into your bottom (rectum), where it dissolves
- through an enema – where fluid is pumped into your large intestine
How you take 5-ASAs depends on the severity and extent of your condition.
If you have mild-to-moderate ulcerative colitis, you'll usually be offered a 5-ASA to take in suppository or enema form.
If your symptoms do not improve after 4 weeks, you may be advised to take 5-ASA in tablet or capsule form as well.
These medicines rarely have side effects, but some people may experience:
They can be used with or instead of 5-ASAs to treat a flare-up if 5-ASAs alone are not effective.
Like 5-ASAs, steroids can be administered orally, or through a suppository or enema.
But unlike 5-ASAs, corticosteroids are not used as a long-term treatment to maintain remission because they can cause potentially serious side effects, such as weakening of the bones (osteoporosis) and cloudy patches in the lens of the eye (cataracts), when used for a long time.
Side effects of short-term steroid use can include:
- weight gain
- increased appetite
- mood changes, such as becoming more irritable
- difficulty sleeping (insomnia)
Immunosuppressants, such as tacrolimus and azathioprine, are medicines that reduce the activity of the immune system.
They're usually given as tablets to treat mild or moderate flare-ups, or maintain remission if your symptoms have not responded to other medicines.
Immunosuppressants can be very effective in treating ulcerative colitis, but they often take a while to start working (usually between 2 and 3 months).
The medicines can make you more vulnerable to infection, so it's important to report any signs of infection, such as a high temperature or sickness, promptly to a GP.
They can also lower the production of red blood cells, making you prone to anaemia.
You'll need regular blood tests to monitor your blood cell levels and check for any other problems.
Treating severe flare-ups
While mild or moderate flare-ups can usually be treated at home, more severe flare-ups should be managed in hospital to minimise the risk of dehydration and potentially fatal complications, such as your colon rupturing.
In hospital, you'll be given medicine and sometimes fluids directly into a vein (intravenously).
The medicines you have will usually be a type of corticosteroid or an immunosuppressant medicine called infliximab or ciclosporin.
Ciclosporin works in the same way as other immunosuppressant medicines by reducing the activity of the immune system.
But it's more powerful than the medicines used to treat milder cases of ulcerative colitis and starts to work much sooner (normally within a few days).
Ciclosporin is given slowly through a drip in your arm (an infusion) and treatment will usually be continuous, for around 7 days.
Side effects of intravenous ciclosporin can include:
- an uncontrollable shaking or trembling of part of the body (a tremor)
- excessive hair growth
- extreme tiredness (fatigue)
- swollen gums
- feeling and being sick
Ciclosporin can also cause more serious problems, such as high blood pressure and reduced kidney and liver function, but you'll be monitored regularly during treatment to check for signs of these.
Infliximab, adalimumab, golimumab and vedolizumab are medicines that reduce inflammation of the intestine by targeting proteins the immune system uses to stimulate inflammation.
These medicines block these receptors and reduce inflammation.
They may be used to treat adults with moderate to severe ulcerative colitis if other options are not suitable or working.
Infliximab may also be used to treat children or young people aged 6 to 17 with severe ulcerative colitis.
The treatment is given for 12 months unless the medicine is not working well.
Read the full NICE guidelines on:
- infliximab, adalimumab and golimumab for treating moderately to severely active ulcerative colitis after the failure of conventional therapy
- vedolizumab for treating moderately to severely active ulcerative colitis
Infliximab is given as an infusion over the course of 1 to 2 hours. You'll be given further infusions after 2 weeks, and again after 6 weeks.
Infusions are then given every 8 weeks if treatment is still required.
Common side effects of infliximab can include:
- increased risk of infection – report any symptoms of a possible infection, such as coughs, a high temperature or a sore throat, to a GP
- the sensation that you or the environment around you is moving (vertigo) and dizziness
- an allergy-like reaction, causing breathing difficulties, hives and headaches
In most cases, a reaction to the medicine occurs in the first 2 hours after the infusion has finished.
But some people experience delayed reactions days, or even weeks, after an infusion.
If you begin to experience the symptoms listed above after having infliximab, seek immediate medical assistance.
You'll be carefully monitored after your first infusion and, if necessary, powerful anti-allergy medicine, such as epinephrine, may be used.
This is because there have been a number of cases where infliximab has reactivated dormant infections.
Tofacitinib is a newer type of medicine for ulcerative colitis.
It also works by targeting the immune system, but does this in a different way from other medicines.
The tablets are recommended for people with moderate to severe ulcerative colitis if standard treatments or biologics have not worked or are not suitable.
Tofacitinib is not recommended for use in pregnancy. Women should use reliable contraception when taking it, and for at least 4 weeks after finishing the course.
If you have frequent flare-ups that have a significant effect on your quality of life, or you have a particularly severe flare-up that's not responding to medicines, surgery may be an option.
Surgery for ulcerative colitis involves permanently removing the colon (a colectomy).
Once your colon is removed, your small intestine will be used to pass waste products out of your body instead of your colon.
This can be achieved by creating:
- an ileostomy – where the small intestine is diverted out of a hole made in your tummy; special bags are placed over this opening to collect waste materials after the operation
- an ileoanal pouch (also known as a J-pouch) – where part of the small intestine is used to create an internal pouch that's then connected to your anus, allowing you to poo normally
Ileoanal pouches are increasingly used because an external bag to collect waste products is not required.
As the colon is removed, ulcerative colitis cannot come back again after surgery.
But it's important to consider the risks of surgery and the impact of having a permanent ileostomy or ileoanal pouch.
Help and support
Living with a condition like ulcerative colitis, especially if your symptoms are severe, can be a frustrating and isolating experience.
Talking to others with the condition can provide support and comfort.
Crohn's and Colitis UK provides information on where you can find help and support.