Ulcerative colitis (UC) is a disease that belongs to the so-called idiopathic inflammatory bowel diseases (IBD). The exact etiology of IBD and especially EC is not known.
The current view is that it occurs in people with a genetic predisposition and involves a strong stimulation of the immune system, possibly against elements of the microbial flora of the large intestine.
What are the symptoms of ulcerative colitis?
Symptoms of EC usually include:
• diarrheal stools mixed with blood and mucus
• feeling compelled to defecate
• feeling of tension
• abdominal pain
• fever
These symptoms can exist for quite a long time without a diagnosis of the disease. In the laboratory control, inflammation markers may be found increased, while it is possible that there is also a drop in hematocrit and iron due to blood loss.
The test of choice for diagnosis is colonoscopy or at least rectosigmoidoscopy (essentially a low colonoscopy) in cases of flare-up.
The severity of the disease varies and can be mild (fewer than 4 diarrheal stools without blood), moderate (more than 4 but less than 6 diarrheal stools per day) or severe (more than 6 diarrheal stools with admixture of blood, as well as the presence of systemic symptoms such as fever and/or tachycardia).
Depending on the severity and extent of the disease, appropriate treatments are administered.
What drug treatments are available?
The available drug treatments for EC are:
• corticosteroids, i.e. cortisone
• aminosalicylates
• immunomodulators: azathioprine and 6-mercaptopurine,
• biological agents: infliximab, adalimumab, golimumab, vedolizumab, ustekinumab
• small molecules: tofacitinib
In failure of all the above and as a last resort there is surgical treatment.
What is the route of administration of the drugs?
The routes of administration of the above drugs are:
A) orally
B) from the rectum in the form of a suppository or enema (enema)
C) subcutaneously, i.e. by injections in the abdomen
D) intravenously, i.e. by administration into the vein
The corticosteroids they are administered orally, intravenously and in special cases they can also be administered rectally. Aminosalicylates are administered both orally and rectally by enema, whereas immunomodulatory drugs are administered orally only. Biological agents can be administered intravenously and subcutaneously (that is, by injections made in the abdomen by the patient himself). Tofacitinib is given orally.
The aminosalicylates they are usually the first line of treatment and are given in mild cases of the disease. They can be given for both induction and maintenance of remission.
If the patient has frequent flare-ups of the disease and needs multiple cortisone treatments, then the administration of immunomodulators is required. The biological factors they are mainly chosen in those patients who have not responded to the previous treatments. There are, of course, cases of very severe exacerbation of the disease where biological agents can be used from the beginning. The choice of treatment depends on the special characteristics of the disease (severity, extent, etc.), the age of the patient, the existence of comorbidities and the presence or not of extraintestinal manifestations.
What are the risks of the treatment? How long will I take it for?
A question that often torments patients is side effects and the duration of treatment. It seems that all drugs are relatively safe, as long as their use is appropriate. More specifically, aminosalicylates have minimal side effects and are mostly idiosyncratic. The main one is interstitial nephritis, a damage to the kidneys, which is extremely rare and if diagnosed in time has no further consequences.
Immunomodulators are the most difficult drugs for the patient and physician, as they come with a host of side effects such as pancreatitis, myelosuppression, increased risk of viral infections, increased risk of non-melanoma skin cancer, and increased risk of lymphoma . Nevertheless, it must be emphasized that the risk of these side effects is relatively low and does not prevent us from administering them. Finally, biological agents, which have been used for more than 20 years, are drugs that we now know quite well and can use safely. With the data we currently have from the medical literature there may be little
increased risk for infections and even less for skin melanoma for patients taking anti-TNF (infliximab – adalimumab – golimumab). Vedolizumab binds exclusively to the gut and does not increase the risk of infections, nor has it been associated with malignancies to date.
Symptoms in the joints are reported by several patients, but this usually subsides over time. Ustekinumab is also a fairly safe and effective treatment, with good long-term efficacy. So far, no particular adverse effects have been reported from its use. Finally, tofacitinib is a relatively new drug and we don’t have enough data, but we certainly know that it increases the risk for viral infections and especially for shingles resurgence. Therefore, it is recommended to be vaccinated before starting the treatment, if the clinical conditions allow it. In addition, tofacitinib has been associated with thrombosis events and for this very reason its use has been prohibited in special population groups such as smokers, people with cardiovascular diseases, the elderly, etc.
As for the duration of treatment, the current view is that it continues for life. Nevertheless, in selected cases where there is a so-called deep remission of the disease, the treatment may be stopped in consultation with the patient. In any case, however, at least 50% of patients will relapse within two years, which should determine the choices of both the doctor and the patient.
IN CONCLUSION
Ulcerative colitis is an autoimmune disease that affects the colon with varying degrees of severity each time. The main symptom is bloody diarrheal stools and a colonoscopy is required for the diagnosis. Fortunately, today there are a multitude of treatment options, but they must be chosen appropriately in order to have the maximum effect with the maximum possible safety.
They write:
Apostolos Dailianas
Gastroenterologist
Director of the 1st Gastroenterology Clinic HYGEIA
Pantelis Karatzas
Gastroenterologist
Partner of the 1st Gastroenterology Clinic HYGEIA
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