Evidence-based management of ulcerative colitis

Ulcerative colitis (UC) is a chronic inflammatory disorder of the gastrointestinal tract, the exact etiology of which remains unknown. The prevalence in the general population is around 0.25%, and the condition represents a considerable financial burden to the health service. The natural history of the condition is one of periods of remission, punctuated by relapses of disease activity. Medical therapy aims to minimise the frequency of these relapses, as well as the need for glucocorticosteroids, which have potentially deleterious effects. In those with acute severe disease, however, glucocorticosteroids are probably effective, as are infliximab and cyclosporine. In those with a mild to moderate flare of disease activity, oral or topical 5-ASAs, or in combination, are more effective than placebo for induction of remission. Doses of oral 5-ASAs in excess of 2g/day appear to lead to higher likelihood of successful remission. Once remission has been achieved, there is evidence to support the use of oral or topical 5-ASAs, and azathioprine to prevent relapse of disease activity. Again, doses of 5-ASA in excess of 2g/day are associated with a lower risk of relapse. Individuals with chronic relapsing and remitting disease activity are difficult to manage, and may require colectomy with ileal pouch anal anastamosis. Granulocyte/monocyte adsorptive apheresis could be of benefit in this setting, but most trials have been conducted in the Far East, so the efficacy in Western UC patients is unclear.