What to Know About Oral Meds for UC
Get the details on your treatment options when you’re battling ulcerative colitis.
If there’s any good news for people with ulcerative colitis (UC), it’s that today, there are more treatment options than ever. Along with injections and infusion, there are also medications you can take orally, including aminosalicylates, steroids, and immunosuppressive drugs. In all cases, the main goal of UC treatment is to achieve and maintain remission. It’s your UC’s progression in relation to those goals that determines the type of med that might be most effective for you, says Rudolph A. Bedford, M.D., a gastroenterologist at Providence Saint John’s Health Center in Santa Monica, CA.
“With UC, it depends on the severity of the disease,” he explains. “Typically, in patients with mild UC, we may very well be able to control them with a variety of oral medications and not necessarily biologics.”
Let’s look at the oral medications your doctor may consider in treating various aspects of UC.
Treatments That Target UC Inflammation
Aminosalicylates, which contain 5-aminosalicylic acid, or 5-ASA, are prescription anti-inflammatory agents used to fight UC. This drug class has been the first treatment in the majority of mild to moderate UC patients for decades, according to a study in Therapeutic Advances in Gastroenterology. Aminosalicylates include the following medications:
Asacol HD (mesalamine)
Mesalamine drugs are the most common type—at least five treatments on the market include it in their formulation, says Benjamin Hyatt, M.D., a gastroenterologist at Middlesex Digestive Health & Endoscopy Center in Acton, MA. Mesalamine stops the body from making a substance that might cause inflammation. “Think of it as sort of an anti-inflammatory for the GI tract,” Dr. Hyatt says. “They’re effective for what we call induction, meaning making people better acutely when they’re flaring, if they have mild to moderate disease. It’s also useful and effective for maintaining people in remission from their inflammation—so it both makes people better and keeps them better.”
Mesalamine meds are wrapped in an important protective coating, and include a delayed-release tablet or capsule (allowing it to be released where it’s needed in your intestines), a controlled-release capsule (so it goes throughout your digestive system), and an extended-release capsule (making it long-acting). How often you take these meds will be determined by your doctor, and can vary, but you could take it anywhere from one to three times a day.
In addition to your oral med, your doctor might also have you take 5-ASA agents rectally, as a suppository or enema formulation, for best inflammation-lowering results.
The aminosalicylates class of meds comes with possible side effects, including:
Abdominal pain and cramping
Loss of appetite
Some potential side effects—like chest pain, shortness of breath, bloody vomit, pancreatitis—can be serious, so tell your doctor right away if you’re experiencing any new symptoms.
Treatments That Target a UC Flare
The most common meds used for flares are corticosteroids, often called steroids for short. These include:
Entocort EC (budesonide)
“Steroids can be used in the short term to help induce remission,” often for mild to moderate UC, explains David M. Poppers, M.D., Ph.D., a gastroenterologist at NYU Langone Health in New York City. They’ve been around a while—first used as therapy for IBD in the 1950s—and now they’re mainly used to treat UC flares, or for short-term control of IBD symptoms and disease activity.
They shouldn’t be used long-term because they work by suppressing the immune system, so although they stop inflammation, they also make people more vulnerable to infections and impact other areas of the body that can lead to additional damaging side effects. Those can include:
High blood pressure (hypertension)
High blood sugar
Increased facial hair
Rounding of the face (called a “moon face”)
Also, steroids don’t work for everyone, with 20% to 30% of UC patients not responding to them during a flare. But when they do work, patients can see symptom improvement in only a few days of taking them daily.
Treatments That Target the Immune System
Oral immunomodulators are drugs that modify the immune system’s response, decreasing the inflammatory response. They can help prevent the need for longer use of steroids, earning them the name ““steroid-sparing” drugs. With this does come an increased risk of infection from a weakened immune system, as well as a raised risk for some cancers.
Drugs in this class include:
Immunomodulators are used mainly to maintain remission. However, they have a slow “onset of action,” and can take up to six months of regular use to have a full impact. So they might be combined with faster acting drugs, like a steroid or biologic.
“But we don’t use them quite as much anymore, mainly because we have newer biologic therapies that are even safer than these medicines,” Dr. Hyatt points out.
Side effects differ by drug; for instance, potential side effects of azathioprine and 6-mercaptopurine include:
More recently, there has been a new addition to oral medications that can target the immune system. Part of a class of immune system modifiers called sphingosine-1-phosphate (S1P) receptor modulators, these meds alter the immunity responses involved in heart rate, immunity, smooth muscle, and blood vessel cell function. S1P medications options include:
These medications have traditionally been used to treat MS. But in March 2021, the FDA approved Zeposia (ozanimod) for treatment of moderate-to-severe UC.
Side effects for S1Ps include:
Elevated liver enzymes
High blood pressure
Low blood pressure when you stand up (orthostatic hypotension)
Painful and frequent urination (signs of urinary tract infection)
Upper respiratory tract infections
Certain conditions may not allow you to pursue this line of treatment so make sure that your doctor is aware of your full medical history.
Sizing Up Your UC Meds
You’ll know if your UC meds are working because you feel better, and your lab results are better, too. On the flip side, if your medications stop working, you might need to switch to another treatment, or even consider surgery. An estimated 20% to 40% of UC patients don’t respond to conventional medications and might need secondary drug treatment or surgery, according to a 2015 study in Gut and Liver.
So how do you know what’s working or not? This is what Dr. Bedford recommends if you suspect your meds aren’t cutting it:
If, after several weeks (or another period of time defined by your doctor) of taking an oral UC medication, you find that your UC symptoms are not improving, seek help. “It is certainly time to speak to your doctor,” he says.
If you’re experiencing unexplained side effects, reach out to your doctor ASAP.
Speak to your doctor about other potential treatment strategies, like biologic agents, and what you’ll need to do next to start new treatment.
As new oral drugs come on the market (like tofacitinib, an oral med that effectively treats moderate to severely active UC) and research continues in the field, more and more options should become available, hopefully helping reduce side effects and other issues related to current therapy. And in the future, oral biologics might even replace most UC treatments, Dr. Bedford predicts. But for now, if you’re on conventional oral meds, make sure to take them as directed and tell your doctor about any issues that might require a change in therapy.
Aminosalicylates: Crohn’s & Colitis Foundation. (October 2018.) “Fact Sheet. Aminosalicylates.” https://www.crohnscolitisfoundation.org/sites/default/files/legacy/assets/pdfs/aminosalicylates.pdf
Stats on Aminosalicylates and UC: Therapeutic Advances in Gastroenterology. (July 2011.) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3131170/
More on Mesalamine: MedlinePlus. (June 8, 2021.) “Mesalamine.” medlineplus.gov/druginfo/meds/a688021.html
Corticosteroids: Crohn’s & Colitis Foundation. (October 2018.) “Fact Sheet. Corticosteroids.” https://www.crohnscolitisfoundation.org/sites/default/files/legacy/corticosteroids.pdf
Immunomodulators: Crohn’s & Colitis Foundation. (October 2018.) “Fact Sheet. Immunomodulators.” https://www.crohnscolitisfoundation.org/sites/default/files/legacy/assets/pdfs/immunomodulators.pdf
Sphingosine-1 Phosphate Receptor Modulators: (1): U.S. Pharmacist. (January 19, 2021.) “Sphingosine-1 Phosphate Receptor Modulators in the Treatment of Multiple Sclerosis.” https://uspharmacist.com/article/sphingosine1-phosphate-receptor-modulators-in-the-treatment-of-multiple-sclerosis
Sphingosine-1 Phosphate Receptor Modulators: (2): Pharmacy Times. (June 1, 2021.) “FDA Approves Ozanimod as Oral Treatment for Moderately to Severely Active Ulcerative Colitis.” https://www.pharmacytimes.com/view/fda-approves-ozanimod-as-oral-treatment-for-moderately-to-severely-active-ulcerative-colitis
Nonresponse to Meds: Gut and Liver. (January 9, 2015.) “Current and Emerging Biologics for Ulcerative Colitis.” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4282853/