Doctor Q&A: How to Manage Ulcerative Colitis
Ulcerative colitis (UC) is a complicated autoimmune disease that can affect different people in different ways. There isn’t one cure-all, so working with your doctor to tailor a management and treatment plan that works for your body is essential. We asked Dr. Constance A. Pietrzak, a gastroenterologist with Advocate Medical Group in Chicago, about different treatment options and lifestyle changes that can help you manage UC.
What is ulcerative colitis?
Ulcerative colitis (UC) is a condition involving chronic inflammation of the large intestines, or colon. It is one of the two main types of inflammatory bowel disease (IBD), the other being Crohn’s disease. The inflammation in UC is confined to the innermost lining of the colon wall. It starts in the rectum and spreads continuously throughout the colon. Symptoms of UC include diarrhea (often bloody), abdominal pain, weight loss, urgency and loss of appetite. While the exact cause for UC is not known, the three main factors contributing to the disease include genetics, environmental factors and the body's immune system reacting and activating an inflammatory response against the gastrointestinal (GI) tract.
How does UC differ from Crohn’s disease?
There are several differences between UC and Crohn's. UC affects only the colon, whereas Crohn's disease can affect any part of the GI tract from the mouth to the anus. The inflammation in UC is continuous, whereas Crohn's disease can be patchy with areas of inflammation mixed in with areas of the GI tract appearing normal. The inflammation in UC is limited to the innermost lining of the colon wall. With Crohn's disease, the inflammation extends beyond this inner lining through the entire thickness of the gut wall.
Who is most at risk for developing UC?
Again, the exact cause for UC remains unclear, but several risk factors have been identified. Most people are diagnosed between the ages of 15 and 40, with a second peak occurring between the ages of 50 and 80. UC has been found to be more common in the Jewish population than among non-Jews, and it is more common in Caucasians than African-Americans or Hispanics. Given the genetic component to UC, anyone with a family history is at higher risk for the disease. Ten to 25 percent of individuals with UC or Crohn's have an immediate family member with IBD.
Diet also plays a role in the development of UC. Certain foods—such as nuts, coffee or spicy meals-- are thought to trigger an immunologic response potentially resulting in the development of UC, although no food has been identified as a consistent trigger. More recent studies have suggested that an imbalance in an individual's microbiome (the normal bacteria that lives in the gut) may correlate with higher risk of developing IBD. Such an imbalance can result from antibiotics.
Can you discuss some of the common treatments (corticosteroids, antibiotics, biologics)?
Treatment of UC is based on disease severity: mild, moderate, or severe. Different types of medications are commonly used, including aminosalicylates (5-ASAs), corticosteroids, immunomodulators, and biologics.
5-ASAs, such as mesalamine or sulfasalazine, work to decrease inflammation at the level of the lining of the GI tract. These medications are administered as a tablet by mouth, enema, or rectal suppository. They are effective for mild to moderate UC.
Corticosteroids, such as prednisone, methylpredisolone, and budesonide, suppress the immune system. They can be administered intravenously, orally, or through enemas and suppositories. They are used in patients with moderate to severe UC. Because steroids suppress the entire immune response, they do have potential for significant side effects and are only used to induce remission and not long-term for maintenance of remission. The one exception is budesonide, which works locally to decrease inflammation, thereby resulting in minimal systemic effect. Steroids should never be stopped abruptly as this could have significant consequences.
If a patient is not responding to 5-ASAs and corticosteroids, then immunomodulators are used. These include 6-mercaptopurine (6-MP) and azathioprine. Immunomodulators suppress the immune response so that ongoing inflammation cannot occur. These medications can affect the liver and blood cells, therefore, blood counts and liver function tests need to be done frequently when they are being used.
Biologics, such as adalimumab and infliximab, are made from things found in life (proteins), which target specific parts of the immune response found at high levels in patients with UC. One example of a target is tumor necrosis factor alpha (TNF-alpha). Biologics are therefore antibodies which bind to targets (proteins) of the immune response interfering with inflammation. They are typically used for patients with moderate to severe UC and administered intravenously or through injection under the skin. They do, however, weaken the immune system and increase risk for infection.
While all of these medications are safe, if patients experience any side effects or develop fevers/symptoms of illness, they should contact their doctor.
What are your thoughts on biologics and when a patient should consider using them?
Biologics work very well for patients with moderate to severe UC. In the past, these medications were typically started when someone did not respond well to 5-ASAs, corticosteroids, or immunomodulators. This is referred to as the "step-up" approach. Now, however, patients are started on biologics earlier without trying the other types of medications (known as "step-down" therapy). While they have potential for causing significant side effects, biologics are very effective and should be considered in patients earlier in their disease. Patients should be closely monitored for side effects and efforts should be made to lower risk for side effects, such as screening for infections before starting therapy, staying out of the sun, and vaccinations.
Diet plays a big role in UC. In what ways should a person with UC alter their diet?
The goal for dietary changes in a person with UC is to improve and maximize nutrition and avoid any food triggers. Patients should work closely with their doctors to ensure they are maintaining an appropriate diet. Initially, people with UC should be tested for any nutritional deficiencies. There is no specific diet for UC. Many dietary changes are based on trial and error. Elimination diets can be helpful in identifying trigger foods. Lactose elimination has been shown to be particularly beneficial in those with IBD. Other potential triggers include nuts, fresh vegetables, coffee, or fried/greasy/spicy foods.
Are there any lifestyle changes you would recommend?
Along with dietary modifications, other lifestyle changes are important in preventing relapse. Obesity may contribute to inflammation in the lining of the colon, which may have an effect on disease activity and/or severity. Depression and anxiety are not uncommon in those with UC; therefore, it is important to seek help if you notice changes in your mood, such as sadness, anxiety or extreme worry. Patients with UC should also be encouraged to avoid alcohol consumption.
What can people do to help their doctor treat them?
Aside from being compliant with treatment regimens, patients should pay close attention to symptoms and make note of different triggers or patterns. Patients should be open and honest with their physician regarding any symptoms they are experiencing and questions, fears, or concerns they may have. They should maintain open communication with all health care providers.