Let's Talk About Ulcerative Colitis Medication
Whether your symptoms are mild, severe, or somewhere in between, there's a good chance you'll be able to find a medication that helps you heal.by Lara DeSanto Health Writer
When you’ve been diagnosed with ulcerative colitis (UC), a form of inflammatory bowel disease (IBD), there’s one important thing to know: There are a lot of medications that can help. The flip side? There are a lot of medications that can help! Whether it's an aminosalicylate or one of the newer biologics, your doctor will recommend a drug (or drugs) based on the severity of your UC. We’re here to help you understand all the different medications available, including how they work, risks, benefits, and side effects. The goal always? To get you as symptom-free as possible.
Our Pro Panel
We went to some of the nation’s top UC experts to bring you the most scientific and up-to-date information possible.
Aline Charabaty Pishvaian, M.D.
Director of the Inflammatory Bowel Disease Center
Sibley Memorial Hospital
Jason Schairer, M.D.
Senior Staff Gastroenterologist
Henry Ford Inflammatory Bowel Disease Center
Neilanjan Nandi, M.D.
Director of the Inflammatory Bowel Disease Center
Drexel University School of Medicine
Mesalamine is one of the most common treatments for mild-to-moderate ulcerative colitis. It’s a type of drug called an aminosalicylates (5-ASA), which works to reduce inflammation in your intestinal lining for short- and long-term relief of UC symptoms.
Biologic drugs are medications designed to target key proteins in your immune system that are involved in inflammation. They’re typically recommended for people with moderate-to-severe UC. By working to reduce inflammation at the source, biologic drugs can help reduce UC symptoms and potentially help you achieve remission.
Steroids are typically used as a short-term treatment for UC because risks and side effects are common. They can include an increased risk of infections, high blood pressure, insomnia, weight gain, osteoporosis, and more.
If you are at risk of infection or already have an infection, your doctor may prescribe you with antibiotics like Flagyl (metronidazole), Cipro (ciprofloxacin), Vancocin (vancomycin), or Xifaxan (Rifaximin). The specific antibiotic you’re prescribed will depend on the type of infection—for example, Vancocin is typically used to treat infection with the bacteria C. difficile. In most cases, these antibiotics will be given in pill form. Sometimes, however, you’ll need to get them through an IV.
What Medications Are Available for Ulcerative Colitis Treatment?
As you probably know by now, especially if you’ve been diagnosed, UC is a chronic, systemic inflammatory condition that primarily targets the colon and rectum (though body-wide symptoms like fatigue and joint pain are common). Treatments for UC, which causes painful ulcers to form in the large intestine, have improved a great deal in the past few decades, and there are more medication options than ever before.
But which one is right for you? Well, your gastroenterologist (GI) will consider your symptoms, your disease severity, and more to help narrow down the meds that may work best for you. Together, you’ll work to figure out an ideal treatment plan to tackle your specific symptoms.
The main goal of UC treatment is to lower the inflammation in your large intestine and beyond, reducing the frequent diarrhea, urgency, and pain that come with this condition—hopefully getting you into remission and/or helping you maintain it.
Some UC drugs are taken in pill or suppository form, while others are given as an injection or infusion (through an IV). The main types of UC medications include:
In some cases, your doctor also may suggest certain over the counter (OTC) drugs or prescribe antibiotics.
Now let’s dive deeper into each class of drugs available for UC.
Aminosalicylates (5-ASAs) are a group of drugs often recommended for people living with mild-to-moderate UC (in poop terms, that means you’re having fewer than four loose stools a day with only mild cramping.)
These medications are compounds that contain what’s called 5-aminosalicylic acid (5-ASA), which inhibits the body’s ability to make prostaglandins. Lower levels of these hormones can mean less pain and inflammation in the colon, improving UC symptoms in both the short- and long-term. Some 5-ASAs may also be prescribed to treat inflammation of the joints that can sometimes accompany UC.
Of the many UC drugs available, 5-ASAs have the fewest number of risks associated with them. And unlike most other medications for IBD, 5- ASAs don’t suppress your immune system.
In cases of mild to moderate UC, 5-ASAs may be all you need, according to a study in Expert Review of Clinical Pharmacology. They’ve been shown to induce remission or help you maintain remission without the use of other drugs.
There are four main types of 5-ASAs. They include:
Azulfidine (sulfasalalzine). This was the first-ever 5-ASA to be used for the treatment of IBD. If you have mild-to-moderate UC, your doc may prescribe this oral pill as a standalone drug treatment. If you have a severe case, your doctor may also recommend this drug as an adjuvant therapy (meaning it’s taken along with other medications). The sulfa contained in this particular drug can cause negative reactions in some people—in that case, other 5-ASAs typically work better. One thing to be aware of: Infertility and low sperm count have been seen in some men who have taken this drug—however, the effect goes away after the drug is stopped. Azulfidine should not be used in pregnancy. In addition, 2 mg Folate should be prescribed if a patient is on sulfasalazine.
Mesalamine. This 5-ASA comes in multiple forms: Pills, a rectal suppository, and an enema. Those who experience sulfa-related side effects with Azulfidine typically do well on mesalamine.
Oral form: Mesalamine comes in pill form under brand names Asacol HD, Pentasa, Lialda, Apriso, and Delzicol. The only difference between these brand-name drugs is the coating, which helps ensure the drug makes it all the way to your large intestine, where it can do its inflammation-fighting work. The specific coating affects how quickly the drug gets to its target. Depending on the version you’re prescribed, you’ll need to take a dose once, twice, or three times per day.
Suppository form: You can also get mesalamine in a suppository form that you insert into your rectum. The brand name for this drug is Canasa, and it’s usually taken once or twice a day. Taking medicine this way can be unpleasant (here are some tips to make it easier!), but it works particularly well for people who have a type of UC called proctitis, meaning inflammation is confined to the rectum and not the colon. Mesalamine suppositories often help to relieve UC symptoms like the urgent need to have a bowel movement and frequent diarrhea. Sometimes oral and rectal versions of this drug are used together to be even more effective.
Enema form: Lastly, you can get mesalamine in the form of an enema (an injection of fluid into your bowel), typically done once a day. This form of mesalamine is sold under the brand name Rowasa. An enema allows you to deliver the drug directly to the left colon, which is higher up than a suppository goes. People with inflammation specifically in the left colon may find relief from this option.
Dipentum (olsalazine). This is another 5-ASA that can treat UC, taken in capsule form by mouth. It’s typically prescribed to help maintain remission in people with UC who can’t tolerate Azulfidine.
Colazal and Giazo (balsalazide). These 5-ASAs are taken as oral pills to treat mild-to-moderate UC. Giazo is usually only prescribed for males with UC who are over the age of 18 (it wasn’t shown to be effective in women in clinical trials), while Colazal can be used in anyone over age 5.
Side Effects and Safety
5-ASAs, like all medications, may come with certain side effects—but they’re among the safest of all the UC medications. That said, potential side effects include:
loss of appetite
People who have kidney problems should avoid using 5-ASAs because in rare cases they can cause kidney inflammation and harm function. While on 5-ASAs, you’ll need regular kidney tests, which typically means yearly blood and urine tests. Generally, these drugs are safe to use even if you’re pregnant or breastfeeding.
Your doc may prescribe corticosteroids (steroids for short) if you have moderate-to-severe UC, you’re flaring up in a big way, and you need effective treatment like right now.
These babies can noticeably improve your symptoms in as little as a few days. That’s because they reduce the functioning of inflammation-causing chemicals. But it’s not all sunshine and butterflies here—it’s important to know that steroids are not a long-term treatment solution. That’s because they suppress the entire body’s immune system, which can cause an array of other health problems when they’re used too long. (We’ve got more details below.)
For that reason, your GI will likely try to limit your steroid use to short-term courses (like less than a couple of months) to help get UC flares under control.
Steroids for UC can be given orally, rectally, through an IV, or as an injection.
Deltasone (prednisone). This is a common steroid prescribed for many health conditions, including UC. It’s absorbed throughout the digestive tract, which can make it particularly effective for tamping down on symptoms beyond the gut.
Entocort EC (budesonide). This modified steroid is absorbed in the small intestine and the colon, so it gets right to the source. Unlike prednisone, Entocort EC is metabolized by the liver in such a way that its effects on the rest of the body, along with risks and side effects, are minimized.
Uceris (budesonide-MMX). This steroid is basically the same as Entocort EC, save for the added special coating that helps the drug better reach your colon. Compared with other steroids, Uceris may be more effective in inducing remission for people with UC, according to a review in Cochrane Database of Systematic Reviews. Your doctor may recommend this version if your UC inflammation is mainly in your colon.
Suppositories (hydrocortisone). Steroids delivered via a rectal suppository can be very effective for inflammation affecting your rectum and anus, and especially for symptoms like frequency and urgency. The more localized delivery also helps to limit its exposure to the rest of your body, reducing the risk of side effects. That said, it’s still not recommended for long-term use because it’s linked to a condition called steroid myopathy, which can cause weakening of the muscles in your rectum and anus (basically the last thing you need).
Enemas (hydrocortisone, methylpredisone, and Cortenema). Enemas, which are injections of fluid into your colon, help target colon inflammation that suppositories can’t quite reach. Getting the drug this way also helps limit the potential for unwanted systemic effects of steroids.
Rectal foams (hydrocortisone acetate, Uceris, and Proctofoam-HC). Foams help the drug stay in your rectum for longer periods, and they travel throughout your large intestine more effectively.
Side Effects and Safety
Again, because steroids suppress the immune system throughout the whole body, they are associated with a high risk of side effects—especially if used long-term and in high doses. Typically, doctors will only prescribe them for 8 to 12 weeks. For example, people on steroids may experience:
Higher risk of infections, especially yeast infections of the mouth, urinary tract infections, and infections of the female reproductive organs
High blood pressure
Increase in facial hair
Osteoporosis, or weakened bones
These side effects typically go away after you stop taking the steroid—except for in the cases of osteoporosis and cataracts, which is another reason why keeping your exposure limited is so important. Your doctor will weigh the risks and benefits before recommending you try a steroid to treat your UC.
These drugs alter the way your immune system operates—either suppressing it or changing the way it functions—to short-circuit inflammation. Typically, these are given orally as a long-term treatment for UC.
These drugs may be used alone or in conjunction with another drug to treat moderate-to-severe UC. For example, your doctor may suggest immunomodulators if your UC hasn’t responded to 5-ASAs or steroids, or if you’re trying to get off steroids or avoid them entirely. Your doctor also may prescribe an immunomodulator to help make your biologic more effective and/or to help prevent UC flare-ups.
One downside is that they can take three-to-six months to take effect—which can feel like forever if you’re in a lot of pain or discomfort. That’s why in some cases, low-dose steroids may be started along with an immunomodulator to help reduce your symptoms more quickly.
Azasan, Imuran (azathioprine). Sometimes this medication is prescribed to help maintain UC remission. One review of studies that included about 300 patients found that 56% of those treated with azathioprine were disease-free after one year, according to the report in the Cochrane Database of Systemic Reviews. This drug is also often given along with another drug that works faster, like a biologic or steroid.
Gengraf, Neoral, Sandimmune (cyclosporine). This drug comes either as a pill taken twice a day or as a 24-hour infusion (usually reserved for those who are hospitalized for a severe flare). Cyclosporine can take effect more quickly than some other immunomodulators, and it’s among the most effective one for treating severe UC, according to a 2019 review in Intestinal Research.Cyclosporine it is not a medication that can be taken indefinitely due to its severe side effects.
Prograf (tacrolimus). Another good option for moderate-to-severe UC, tacrolimus can also be used in topical form to treat a skin disorder called pyoderma gangrenosum, which is one of the symptoms people with UC can experience.
Purinethol (mercaptopurine). This is another option to help maintain remission. Like azathioprine, this type is sometimes given along with another drug that is faster-acting to provide symptom relief sooner.
Side Effects and Safety
Immunomodulators affect your immune system’s function, so it may be harder for you to fight off infections or even certain cancers (in rare cases) while you’re on them—that’s why it’s especially important to get regular vaccines for things like the flu and pneumonia.
Depending on the specific immunomodulator you’re taking, common side effects may include headache, nausea, vomiting, diarrhea, and more. And because some of these drugs can impact your blood pressure and kidney function, your doctor may require you to have certain routine blood tests—sometimes as often as every few days for the first few weeks as your dosage is established and then every few months thereafter.
One of the newer types of medication on the block for UC, biologic drugs are unique in that they are actually antibodies, rather than artificially prepared chemicals. They’re also pretty cool: They target key proteins in the immune system that are involved in inflammation, going straight to the source of your UC.
They’re usually used for moderate-to-severe UC and can help you achieve or maintain remission, according to a recent study in Drugs in Context. These are long-term treatment options—once you start a biologic, expect to stay on it indefinitely.
Unfortunately, getting the benefits of biologics isn’t as easy as popping a pill every day. Instead, they’re either given as an injection (you do it yourself at home) or through an IV at a health care provider’s office.
There are three main types of biologics approved for UC treatment: Anti-tumor necrosis factor (TNF) agents, anti-integrins, and anti-IL-12/23 drugs.
These types of biologics work by blocking a protein called tumor-necrosis factor alpha (TNF-alpha) in the body. This protein is known to increase inflammation in your intestines. By taking an anti-TNF agent, you’re working to reduce inflammation from UC and to heal damaged tissues in your gut. Typically, it can take up to eight weeks for symptoms to start improving on this type of biologic.
Humira (adalimumab). This biologic drug can help induce and maintain remission in adults with moderate-to-severe UC. It’s given as an injection in your abdomen or thigh—a health care provider will show you how to do it yourself (or with the help of a family member) at home. Usually, your first dose is four shots, followed by two shots two weeks later, and then one shot every two weeks after that. Note: Your doc may also prescribe one of the often less-expensive biosimilar (meaning they’re almost identical) versions of this biologic, such as Amjevita (adalimumab-atto) or Cyltezo (adalimumab-adbm).
Remicade (infliximab). This biologic can be used in adults and children with moderate to severe UC. Additionally, your doctor may prescribe it to help manage an IBD complication called a fistula, which is a connection between two parts of the body that shouldn’t be there (such as the vagina and rectum). Remicade is given as an infusion via an IV in a health care provider’s office. It takes about two-to-four hours to complete one infusion—so bring a book or load up Netflix on your tablet. After the first dose, usually you get the second dose two weeks later, the third dose four weeks after that, and then a dose every eight weeks from then on. Note: Your doc may also prescribe one of the biosimilar versions of this biologic, such as Renflexis (infliximab-abda), Inflectra (infliximab-dyyb), or IXIFI (infliximab-qbtx).
Simponi (golimumab). This anti-TNF agent can be used to treat moderate-to-severe UC in adults, especially in people who don’t respond to or can’t tolerate other UC medications or those who are struggling to get off steroids. After you get the first two doses, you’ll usually inject a dose once every four weeks.
Entyvio (vedolizumab). Currently the only anti-integrin approved for moderate-to-severe UC, Entyvio works by blocking a protein on the surface of cells that cause inflammation, preventing those cells from moving into your tissue and wreaking havoc. It can help induce and maintain remission—and reduce the need for steroids. Your doctor may also prescribe this drug if your UC hasn’t responded to steroids or has become steroid-dependent. Like Remicade, Entyvio is delivered via infusion, but the infusions are shorter: They take about half an hour. After the first dose, the second dose is given two weeks later, the third dose four weeks after that, and then every eight weeks from then on.
Interleukin-12 and 23 Antagonists
This type of biologic targets the interleukin-23 and interleukin-12 proteins, which have been shown to play a key role in inflammation. The medication in this class approved for UC treatment is called Stelara (ustekinumab). The first dose is an IV infusion based on your body weight, followed by an injection every eight weeks that you can do at home.
Side Effects and Safety
It’s important to know that while biologic drugs don’t come with as many risks as steroids, they still suppress your immune system—that means you’re at increased risk of infection while you’re on them. You’ll need to stay current on routine vaccinations—that means getting your flu shot every year—and call your doctor right away if you have signs of any infection while on these drugs. You also may experience some irritation at the injection or infusion site, along with mild side effects like headache, fever, and hives or rashes.
Lastly, although rare, there’s some evidence that shows that anti-TNF biologics are linked to a slight increase in your risk of lymphoma, a type of blood cancer, along with liver problems or a lupus-like reaction. Your doctor can help you weigh the pros and cons.
Yep, there’s more! To manage your UC in the best way possible, your doctor also may suggest certain over the counter (OTC) drugs, depending on your symptoms, including pain relievers, anti-diarrheal medications, and supplements. They also may prescribe antibiotics if you get an infection or a complication of UC.
Pain relievers. Usually the pain reliever of choice for people with UC is acetaminophen (such as Tylenol). You should typically avoid nonsteroidal anti-inflammatory drugs (NSAIDs) like Advil and Motrin (ibuprofen) as well as Aleve (naproxen), all of which can actually irritate your bowel and make your UC symptoms worse.
Anti-diarrheal drugs. If you’re dealing with bad diarrhea, your GI may suggest you take Imodium (loperamide), which can be purchased OTC. However, you should speak with your doctor first, because anti-diarrheal medications may increase your risk of a complication called toxic megacolon, which, like it’s horror-movie name suggests, is a dangerously enlarged colon.
Supplements. Depending on your UC symptoms and potential deficiencies, your doctor or registered dietitian may recommend you take certain supplements. For example, UC increases the risk of iron-deficiency anemia due to bleeding in the large intestine, so your doctor may want you to supplement iron. In some cases, iron in pill form may be OK—but it can come with side effects like constipation, so an infusion may also be recommended.
Medication overview: The Crohn’s & Colitis Foundation. (2019). “IBD Medication Guide.” ibdmedicationguide.org/
UC background: UpToDate. (2019). “Patient education: Ulcerative colitis (Beyond the Basics)”. uptodate.com/contents/ulcerative-colitis-beyond-the-basics
Treatment Guidelines: American Journal of Gastroenterology. (2019). “ACG Clinical Guideline: Ulcerative Colitis in Adults.” journals.lww.com/ajg/Fulltext/2019/03000/ACG_Clinical_Guideline__Ulcerative_Colitis_in.10.aspx