Posted by Alex
When the acute attack is controlled, a maintenance regimen is usually required, especially in patients with severe, extensive, or relapsing disease. Sulfasalazine, olsalazine, or mesalamine are all effective in reducing relapses. As a rule, patients should not be treated chronically with steroids. Azathioprine or 6-MP may be useful as steroid-sparing agents for steroid-dependent patients, and for maintenance of remission not adequately sustained by aminosalicylates, and occasionally for patients who are steroid-refractory but not acutely ill.
Read the rest of this entry »
Posted by Alex
Patients with mild to moderate extensive colitis should begin therapy with oral sulfasalazine in daily doses titrated up to 4-6 g/day, or an alternate aminosalicylate in doses up to 4.8 g/day. Oral steroids are generally reserved for patients who are refractory to oral aminosalicylates with or without topical therapy, or for patients whose symptoms are so troubling as to demand a “quick fix.” 6-Mercaptopurine (6-MP) or azathioprine are effective for patients who do not respond to oral prednisone but are not so acutely ill as to require intravenous therapy.
When inflammation extends proximal to the reach of topical therapy (i.e., middescending colon-splenic flexure) oral therapy is required, either solely or in combination with topical therapy (though this latter option has not been studied in randomized controlled trials). For clinically mild to moderate, but anatomically extensive disease, the first-line therapy traditionally has been sulfasalazine. Responses are dose related with up to 80% of patients who receive daily doses of 4-6 g manifesting complete clinical remission or significant clinical improvement within 4 weeks [11] [12] and approximately half achieving sigmoidoscopic remission [11] . However, the benefits of greater efficacy with the higher dose are offset by the increase in side effects. The advantages of sulfasalazine compared with the newer aminosalicylates are its longer track record and considerably lower cost. If it happens or is anticipated that these higher doses of sulfasalazine will not be well tolerated, then a 5-aminosalicylate should be used at doses of at least 2 g/day, titrating up to 4.8 g/day [14] .
Read the rest of this entry »
Posted by Alex
Mesalamine suppositories in a dose of 500 mg twice daily are effective in the maintenance of remission, in patients with proctitis, whereas mesalamine enemas (2-4 grams) are effective in patients with distal colitis. Sulfasalazine (2-4 g/day) and mesalamine (1.5-4 g/day) are also effective in maintaining remission, whereas topical corticosteroids, on the other hand, have not proven effective for maintaining remission in distal colitis.
Posted by Alex
Patients with mild to moderate distal colitis may be treated with either oral aminosalicylates, topical mesalamine, or topical steroids. In patients refractory to oral aminosalicylates or topical corticosteroids, mesalamine enemas may still be effective. The unusual patient who is refractory to all of the above agents in maximal doses may require treatment with oral prednisone in doses up to 40-60 mg/day.
The therapeutic plan here is largely determined by the patient’s preference because either oral or topical therapy is effective. Oral therapy with aminosalicylates, either sulfasalazine, olsalazine, or mesalamine, is beneficial in achieving and maintaining remission [1] [9] [10] . Effective doses of sulfasalazine range between 4 and 6 g/day in four divided doses [11] [12] ; for mesalamine, at least 2-4 g/day in divided doses [13] [14] , and for olsalazine 1.5-3 g/day in divided doses [15] [16] [17] [18] , although efficacy of olsalazine in active UC is not conclusively established, perhaps in part because of a confounding dose-related diarrhea. These drugs generally are efficacious within 2-4 weeks [11] [12] [13] [14] [15] [16] [17] [18] and are effective in 40-80% of patients. Intolerance to the sulfapyridine moiety is not uncommon and may result in nausea, vomiting, dyspepsia, anorexia, and headache. More severe, but less common, adverse effects include allergic reactions, pancreatitis, hepatotoxicity, drug-induced connective tissue disease, bone marrow suppression, interstitial nephritis, nephrotoxicity, hemolytic anemia, or megaloblastic anemia. Abnormal sperm counts, motility, and morphology are related to the sulfapyridine moiety and are not seen with the mesalamine preparations. Approximately 80% of patients intolerant to sulfasalazine are able to tolerate olsalazine and mesalamine [9] [18] [19] [20] . However, several of the allergic reactions previously thought to be due to the sulfa moiety have been seen with newer aminosalicylates as well [9] .
Read the rest of this entry »
Posted by Alex
Goals of treatment are directed at inducing and then maintaining remission of symptoms and mucosal inflammation. Once the diagnosis of UC is confirmed, the anatomic extent is assessed endoscopically. The key question to be addressed at this point is whether the inflammation is “distal” (i.e., limited to below the splenic flexure and thus within reach of topical therapy) or “extensive” (i.e., extending proximal to the splenic flexure, requiring systemic medication). Therefore, a delineation of the proximal margin of inflammation, if not achieved on initial evaluation, is desirable at some point in the management of the case once the patient’s condition permits. Read the rest of this entry »
Posted by Alex
In a patient presenting with persistent bloody diarrhea, rectal urgency, or tenesmus, stool examinations and sigmoidoscopy and biopsy should be performed to confirm the presence of a colitis and to rule out infectious causes. Characteristic endoscopic and histologic findings with negative evaluation for infectious causes will suggest the diagnosis of ulcerative colitis.
The diagnosis of UC is suspected on clinical grounds and supported by the appropriate findings on proctosigmoidoscopy or colonoscopy, biopsy, and by negative stool examination for infectious causes. Infectious etiologies of colitis can produce clinical findings indistinguishable from idiopathic UC, so microbiologic studies for bacterial and parasitic infection, as well as serologic testing for ameoba when clinical suspicion is high, should be performed in each new patient and in patients with stable symptoms who develop a severe exacerbation. Similarly, patients who have had recent antibiotics, or have recently been hospitalized, should have stools examined for Clostridium difficile.
Read the rest of this entry »
Posted by Alex
INTRODUCTION
Ulcerative colitis (UC) is a disorder characterized by diffuse mucosal inflammation limited to the colon. UC is usually a chronic disease which involves the rectum and may extend proximally in a symmetrical, circumferential, and uninterrupted pattern to involve parts or all of the large intestine. The hallmark clinical symptom is bloody diarrhea often with prominent symptoms of rectal urgency and tenesmus (painful straining at stool). The clinical course is marked by exacerbations and remissions, which may occur spontaneously or in response to treatment changes or intercurrent illnesses [1] [2]. Ulcerative colitis affects approximately 250,000 individuals in the United States with an incidence of 2-6 per 100,000 people per year; the prevalence has remained relatively constant over the last five decades.
