Management of Mild-to-Moderate Ulcerative Colitis

Managing mild-to-moderate ulcerative colitis on the first view appears to be a simple task. However, real life often proofs the opposite and creates a challenging situation. In theory, mild-to-moderate disease should be sufficiently treated by mesalamine or alternatively by a probiotic. Insufficient treatment comprises the danger of leading to a flare, and hence, an exacerbation of the entire disease, with risk of progressing to severe disease. What are the considerations with regard to patient management in this situation? Certainly, disease distribution is the critical information, since it allows for planning the optimal route of administration, namely local versus systemic treatment. Novel pharmacological strategies might allow for reaching high local concentrations even at the left side of the colon or alternatively administer locally active budesonide throughout the entire colon frame, thus avoiding systemic side effects. Therapy planning has to involve the patient to identify how this can be included in daily life. Including the patient implies that depending on the condition, disease activity and even life quality, the individual therapy requires timely adaption. A recent study by Pedersen et al. [Inflamm Bowel Dis 2014;20:2276-2285] provides evidence that this strategy can be followed and leads to an overall better outcome. A last thought, besides the patient not taking the appropriate dose or lacking adherence to therapy, should consider that a worsening of disease could be due to infectious complications including Clostridium difficile or cytomegalovirus colitis. If all considerations fail within a reasonable time frame, therapy should be escalated. Patients in this situation often hesitate in accepting the need of immunosuppression. Future options, potentially including phosphatidylcholine, might bridge the gap between mesalamine, probiotics and immunosuppressive strategies.