How Is Ulcerative Colitis Treated?
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Medically reviewed by Jay N. Yepuri, MD
Ulcerative colitis (UC) is a type of inflammatory bowel disease (IBD) that affects the large intestine. Inflammation in the inner lining of the colon and rectum can cause ulcers to form, leading to symptoms such as diarrhea, abdominal pain, and bloody stool (poop). There is no cure for ulcerative colitis. Instead, treatment focuses on reducing inflammation so you can enter and stay in a symptom-free period known as remission.
Maintaining remission can control symptoms and prevent complications. Remission can last anywhere from weeks to years. Symptoms can reappear in times known as flares, when treatment will need to refocus on getting you back into remission.
Gastroenterologists—doctors specialized in diagnosing and managing digestive disorders—provide treatment for people with UC. Your gastroenterologist will develop an individualized treatment plan based on how severe your inflammation is, where in your large intestine the inflammation is, and whether you are in a period of remission or flare.
Ulcerative colitis is a chronic condition, and most people require lifelong treatment with medications to achieve and maintain long-term remission and improve their quality of life. In some cases, such as when other treatments are ineffective, surgery is necessary to remove the colon and rectum.
Medications
Medications are a cornerstone of ulcerative colitis treatment. They help reduce inflammation and control symptoms. The medications your healthcare provider prescribes can change over the course of your UC based on factors like whether the inflammation spreads and how your body responds to each medicine.
Aminosalicylates
Aminosalicylates—also referred to as 5-ASAs—are anti-inflammatory compounds that directly target inflammation in the lining of the gastrointestinal tract. These medications are effective for reaching and maintaining remission in people with mild-to-moderate UC.
There are several types of 5-ASAs available, some of which can be taken orally (by mouth) and others that are used rectally (through the rectum). Your healthcare provider may prescribe 5-ASAs in the form of:
Tablets or capsules: These medicines are taken orally. They have a coating or are in special capsules to ensure the drug dissolves when it reaches a certain point of the digestive tract. The medication is manufactured to be either extended-release (the medicine is released throughout the digestive system) or delayed-release (the medicine isn't released until farther into the intestine). Many of these oral medications are mesalamine, sold under brand names like Lialda, Pentasa, Apriso, and Asacol. Another type of 5-ASA is sulfasalazine, sold under the brand name Azulfidine.
Enemas: An enema is a tubed device you insert into your rectum so that liquid medication such as Rowasa (mesalamine) can be pushed directly into the lower portion of your colon.
Suppositories: Rectal suppositories, such as Canasa (mesalamine), deliver high-dose medicine directly to the lower portion of the colon. Once the suppository is inserted into the colon, the medicine dissolves in your colon.
Some healthcare providers prescribe a combination of oral and rectal therapies. The number of tablets or capsules you take each day or how often you use an enema or suppository can vary. If you use a rectal therapy, you will most likely administer it before bed.
Corticosteroids
Corticosteroids are powerful anti-inflammatory drugs that help manage moderate-to-severe UC. The medicines target body-wide inflammation and suppress the body's immune response to reduce inflammation and control ulcerative colitis symptoms.
Your healthcare provider may prescribe corticosteroids to reduce inflammation during a flare-up. Corticosteroids are available in oral and rectal forms:
Oral corticosteroids: Taken by mouth, your healthcare may prescribe Deltasone (prednisone); Entocort (budesonide), which is partially absorbed by the small intestine before reaching the colon; and Uceris (budesonide-MMX), a pill with a special coating that ensures the medicine is delivered directly to the colon.
Suppositories: Hydrocortisone is a corticosteroid rectal suppository that helps reduce rectal inflammation and minimize the frequency and urgency of bowel movements.
Enemas: Liquid corticosteroids, such as Cortenema (hydrocortisone), help reach inflammation higher than the rectum.
Rectal foams: Hydrocortisone acetate (sold under brand names like Uceris and Proctofoam-HC) is a foam you insert into your rectum. The foam consistency helps keep the medicine contained to the rectum and colon.
Corticosteroids effectively control inflammation, and many people experience symptom relief within a few days of taking the medication. However, due to the risk of serious short- and long-term side effects, corticosteroids are only for short-term use.
Immunomodulators
Immunomodulators suppress the immune system to reduce inflammation. Your healthcare provider may prescribe immunomodulators if other treatments are ineffective or you frequently need corticosteroids.
Immunomodulators are oral medications. Imuran (azathioprine), Azasan (azathioprine), or Purinethol (6-mercaptopurine) help maintain UC remission. Severe UC may require immunomodulators like Neorol (cyclosporine A) or Prograf (tacrolimus).
It can take up to six months to notice improvements in symptoms with immunomodulators. For this reason, healthcare providers may prescribe them along with other medications to bolster the effectiveness of treatment.
Targeted Synthetic Small Molecules
Targeted synthetic small molecules reduce inflammation by targeting and interrupting specific parts of the immune system involved in intestinal inflammation. They treat moderate-to-severe UC. The group of medications include Janus kinase (JAK) inhibitors and an S1P receptor modulator.
JAK inhibitors, such as Xeljanz (tofacitinib) and Rinvoq (upadacitinib), are small molecules that break down in the intestine and travel through the bloodstream to block the action of Janus kinases, enzymes that play a role in the signaling pathways involved in inflammation. By blocking these enzymes, JAK inhibitors reduce inflammation in the intestinal lining to relieve symptoms and promote healing in people with UC.
The S1P receptor modulator Zeposia (ozanimod) is an oral pill that works by targeting specific receptors on immune cells (lymphocytes). The drug prevents the lymphocytes' movement from lymphoid tissues into the intestinal lining, where they can cause inflammation. By preventing lymphocytes from reaching the intestines, the medication helps reduce the number of inflammatory cells in the intestinal lining, helping reduce inflammation and control UC symptoms.
Biologics
Biologics treat moderate-to-severe ulcerative colitis. They target and inhibit specific proteins involved in the body's inflammatory process. Biologic medication is delivered via subcutaneous injection (under the skin) or intravenous (IV) infusion. Biologics for treating UC include:
Anti-tumor necrosis factor (TNF) agents: Remicade (infliximab), Humira (adalimumab), Cimzia (certolizumab pegol), Simponi (golimumab), and other anti-TNF agents block a protein called tumor necrosis factor-alpha, which promotes intestinal inflammation. Anti-TNF agents reduce inflammation and UC symptoms.
Integrin receptor agonists: Tysabri (natalizumab) and Entyvio (vedolizumab) prevent inflammatory cells from moving into the intestinal lining by blocking a protein on the cells' surfaces.
Anti-interleukin agonists: Ustekinumab (Stelara) targets interleukin-12 (IL-12) and interleukin-23 (IL-23), two proteins involved in the immune system's inflammatory response. By blocking these proteins, this biologic helps reduce inflammation and symptoms of UC.
Surgery
When symptoms don't improve with medications or complications relating to UC develop, your healthcare provider may recommend surgery to treat ulcerative colitis. The surgery, called a protocolectomy, involves removing the colon and rectum. There are two types of protocolectomy.
One type—a proctocolectomy with ileal pouch-anal anastomosis—involves removing the colon and rectum. A pouch is then made to connect the end of the small intestine to the anus. The pouch mimics the function of the removed colon and rectum so that stool can continue to pass through the anus.
The other type of surgery—a proctocolectomy with end ileostomy—involves removing the colon, rectum, and anus. Surgeons then attach the end of the small intestine to an opening in your abdomen (stoma). Stool passes through the stoma into an ostomy bag—a pouch that attaches to the stoma and sits outside your body.
When determining which surgical approach to perform, your healthcare provider will consider several factors, including age, overall health, and UC severity.
Complementary and Alternative Therapies
While conventional medicine remains the cornerstone of ulcerative colitis treatment, some people find relief by incorporating other therapies into their treatment plans. These therapies may reduce symptoms and improve your quality of life.
Dietary Supplements
Ulcerative colitis can affect your body's ability to absorb some vitamins and minerals, leading to nutritional deficiencies. People with UC tend to have deficiencies in iron, vitamin B12, vitamin D, folic acid, vitamin K, and selenium. If a blood test shows you have a deficiency, you may be told to adjust your diet or take dietary supplements.
Some evidence also suggests that curcumin—the main ingredient in turmeric—and omega-3 fatty acid supplements may help reduce inflammation in people with UC.
Probiotics
The gut microbiome is the make-up of bacteria in your intestines. An imbalance of good vs. harmful bacteria in the gut microbiome is associated with chronic intestinal inflammation. Probiotics are live microorganisms found in certain foods like yogurt and available in supplements that may help balance your gut microbiome.
Some research suggests that certain strains of probiotics help restore balance in the gut microbiome, reducing inflammation to relieve symptoms and promote healing of UC.
Acupuncture
Acupuncture is a traditional Chinese medicine practice that involves inserting thin needles into specific points on the body (acupoints) and manually manipulating the needle (like by gently twisting it) to stimulate the acupoints. Research shows that acupuncture can reduce inflammation and improves symptoms of ulcerative colitis, especially when paired with conventional UC medications.
Lifestyle
While lifestyle modifications alone won't eliminate ulcerative colitis symptoms, adopting certain habits may help reduce the frequency and severity of flare-ups and improve your quality of life.
Diet
Many people with UC find that certain foods and beverages, including high-fiber foods, high-fat foods, spicy foods, alcohol, and artificial sweeteners, trigger or worsen symptoms. Trigger foods vary person to person, so it may help to keep a food diary so you can identify and avoid your triggers.
Some foods, such as red meat, processed meats, and certain oils (including coconut and palm oils), are associated with an increased risk of inflammation. While it's fine to have these foods in moderation, you should limit your intake to keep inflammation under control.
Aim to eat plenty of fruits, cooked vegetables, and foods rich in omega-3 fatty acids, such as salmon, flaxseeds, and tuna. Some people with UC follow specific diets, like an anti-inflammatory diet, though this isn't always necessary.
Working with your healthcare provider or a registered dietician is a good way to create a personalized eating plan that ensures your body gets the nutrients it needs while minimizing flare-ups.
Stress Management
Living with a chronic condition like ulcerative colitis can take a toll on your psychological well-being, and many people with UC find their symptoms worsen during high-stress periods. Stress management techniques promote relaxation, which may help control UC symptoms during stressful times.
While it may take some trial and error to find what works for you, these stress-busting techniques may help promote relaxation:
Completing breathing exercises
Listening to calming music
Doing yoga
Practicing Tai Chi
Spending time in nature
Living With and Managing Ulcerative Colitis
Ulcerative colitis is a lifelong condition that may require you to plan out or make adjustments to your daily routine. Given the unpredictable nature of flares, there may be times when you are in remission and suddenly develop symptoms that interfere with work, social activities, and your overall quality of life. The need for regular check-ups and medication management can further impact your daily routine.
Despite these challenges, it is possible to adapt and thrive while living with ulcerative colitis. Some people find joining UC support groups helpful in connecting with others with similar experiences. Eating a balanced diet and following your treatment plan are also important when living with UC.
A Quick Review
Ulcerative colitis is an inflammatory bowel disease that causes chronic inflammation in your large intestine, including your colon and rectum, leading to symptoms like diarrhea, abdominal cramping, and bloody stool. Medications are the main treatment of ulcerative colitis. There are several types of medications available that can be taken in different ways, including orally or rectally. The medications you're prescribed can depend on disease severity and other factors. Surgery is sometimes necessary when medications are ineffective. On top of medication, dietary changes and stress management may help in treating ulcerative colitis.
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