Enemas ulcerative colitis

Treatment of acute episodes of ulcerative colitis is dictated by the severity and extent of disease, and first-line therapy of mild to moderate disease involves oral or topical aminosalicylate derivatives. Topical suppositories and enemas are preferred for active distal UC (left-sided disease and proctitis), as they deliver mesalamine directly to the site of inflammation. Topical mesalamine is superior to both topical corticosteroids and oral aminosalicylates for inducing remission in active mild to moderate UC.1,33,34 Enemas are appropriate for patients with... 

Maintenance of remission of ulcerative colitis may be achieved with oral or topical aminosalicylates. Mesalamine suppositories 1 g daily may prevent relapse in up to 90% of patients with proctitis.1 Mesalamine enemas are appropriate for left-sided disease and may often be dosed three times weekly. Oral mesalamine at lower doses (e.g., 1.6 g per day) may be combined with topical therapies to maintain remission. Topical or oral corticosteroids are not effective for maintaining remission of distal UC and should be avoided. 

Mesalamine (Asacol, Lialda, Pentasa, Rowasa) [Anti-inflcinimcifory/Seilicyleite] Uses Mild-mod distal ulcerative colitis, proctosigmoiditis, proctitis Action Unknown may inhibit prostaglandins Dose Rectal 60 mL qhs, retain 8 h (enema), 500 mg bid-tid or 1000 mg qhs (supp) PO Cap 1 g PO qid Tab 1.6-2.4 g/d doses (tid-qid) delayed release 2.4-. 8 g PO daily 8 wk max, do not cut/crush/chew w/ food initial dose in elderly Caution [B, M] Contra Salicylate sensitivity Disp Tabs, caps, supp, rectal susp SE HA, malaise, abd pain, flatulence, rash, pancreatitis, pericarditis Interactions X Effect OF digoxin EMS May turn urine yellow-brown OD May cause NA /D, tinnitus, HA, and drowsiness activated charcoal may be effective... 

To avoid the side effects of sulfapyridine, various preparations to target 5-ASA directly to sites of disease have been formulated. Also known as mesalamine, 5-ASA has been formulated in oral forms (Pentasa, Asacoi). Pentasa is a time-release capsule that releases the drug throughout the GI tract. Asacoi is a pH-dependent-release preparation that delivers drug to the distal small bowel and colon. The response of ulcerative colitis to this formulation appears to be identical to that seen with sulfasalazine. Mesalamine can also be administered as a suppository (Canasa) or enema (Rowasa) for distal colonic disease. 

Distal ulcerative colitis, proctosigmoiditis, proctitis Rectal (retention enema) 60 mi (4 g) at bedtime retained overnight for approximately 8 hr for 3-6 wk. Rectal (500-mg suppository) Twice a day. May increase to 3 times a day. Rectal (1,000-mg suppository) Once daily at bedtime. Continue therapy for 3-6 wk. 

Local therapy, such as topical preparations for skin disease, ophthalmic forms for eye disease, intra-articular injections for joint disease, inhaled steroids for asthma, and hydrocortisone enemas for ulcerative colitis, provides a means of delivering large amounts of steroid to the diseased tissue with reduced systemic effects. 

The effectiveness of 5-ASA therapy depends in part on achieving high drug concentration at the site of active disease. Thus, 5-ASA suppositories or enemas are useful in patients with ulcerative colitis or Crohn s disease confined to the rectum (proctitis) or distal colon (proctosigmoiditis). In patients with ulcerative colitis or Crohn s colitis that extends to the proximal colon, both the azo compounds and mesalamine formulations are useful. For the treatment of Crohn s disease involving the small bowel, mesalamine compounds, which release 5-ASA in the small intestine, have a theoretic advantage over the azo compounds. 

Cushing s syndrome occurred in a 65-year-old woman with ulcerative colitis who received a daily betamethasone enema (471). 

Tsuruoka S, Sugimoto K, Fujimura A. Drug-induced Cushing syndrome in a patient with ulcerative colitis after betamethasone enema evaluation of plasma drug concentration. Ther Drug Monit 1998 20(4) 387-9. 

Vitti, R.A., et al. 1989. Quantitative distribution of radiolabelled 5-aminosalicylic acid enemas in patients with left-sided ulcerative colitis. Dig Dis Sci 34 1792. 

Alicaforsen (ISIS 2302) ICAM-1 Ulcerative colitis Topical Enema Isis... 

Based upon these observations and following Phase I safety studies, a Phase II randomized, double-blind, controlled clinical trial was undertaken to treat active ulcerative colitis with escalating doses of ISIS 2302. Based on an intent-to-treat analysis, 59% (13/22) of patients treated daily with 240 mg ISIS 2302 enema over six weeks achieved a positive response, as measured by Disease Activity Index (DAI)... 

Mrs Q is a 37-year-old woman who comes to your pharmacy with a prescription for Predsol enemas, one daily for four weeks. She tells you that she has recently been diagnosed with ulcerative colitis and that this is her first prescription for an enema. She says she would really rather have tablets but the doctor suggested that an enema would be more appropriate for her. 

Purvis J (1988) Enemas in ulcerative colitis. Pharmaceutical Journal 13 August 208. Predsol Retention Enema, Summary of Product Characteristics. Available at http //emc. medicines.org.uk/ [Accessed 7 July 2008],... 

Although systemic absorption of the prednisolone from the enema probably does occur, especially when the colon is particularly inflamed, corticosteroids usually have less systemic effects when given this way. Furthermore, by giving an enema, the drug is being delivered directly to its site of action - remember that in ulcerative colitis the disease is confined to the lower gastrointestinal tract. 

Daily mesalazine 4 g orally plus placebo enema and mesalazine 2 g orally plus mesalazine 2 g rectally as a liquid enema have been compared in the treatment of mild to moderate ulcerative colitis in a multicenter, randomized, double-blind trial in 130 patients (7). The two treatments were equally effective in inducing disease remission. Both were well tolerated, and the frequencies of adverse effects were similar in the two groups. 

In a 4-week, randomized trial in 103 patients with mild to moderate left-sided ulcerative colitis or proctosigmoiditis, mesalazine gel enema 2 g/day was as effective as mesalazine foam enema 2 g/day in inducing remission (102). Patients in the foam group had significantly more... 

In an open, randomized trial in 266 patients with active distal ulcerative colitis, mesalazine foam enema 2 g/day was as effective as mesalazine standard liquid enema 4 g/ day (103). The number of adverse effects attributable to medication was higher in the foam group than in the liquid enema group (14 versus 4). The most commonly reported adverse effect was flatulence. 

Malchow H, Gertz B, CLAFOAM Study group. A new mesalazine foam enema (Claversal Foam) compared with a standard liquid enema in patients with active distal ulcerative colitis. Aliment Pharmacol Ther 2002 16(3) 415-23. 

Yale Medical School investigators reported three cases of ulcerative colitis, in patients with no history of this disease, following the use of H202 in an enema.2 All three recovered, but they were seriously ill. As the authors observed, "sepsis invariably occurs in association with hydrogen peroxide colitis." Sepsis means bacteria in the blood, a potentially fatal complication. 

The first-line of treatment for mild to moderate ulcerative colitis or Crohn s colitis consists of oral sulfasalazine or mesalamine mesalamine or steroid enemas may be used for rectosigmoid disease. Delayed-release oral formulations of mesalamine may be used for Crohn s ileitis. 

D Albasio G, Pacini F, Camarri E, et al. Combined therapy with 5-aminosalicylic acid tablets and enemas for maintaining remission in ulcerative colitis A randomized double-blind study. Am J Gastroenterol 1997 92 1143-1147. 

Lee FI, Jewell DP, Mani V, et al. A randomized trial comparing mesalamine and prednisone foam enemas in patients with acute distal ulcerative colitis. Gut 1996 38 229-233. 

Sanborn WJ, Tremaine WJ, Schroeder KW, et al. Cyclosporine enemas for treatment-resistant, mildly to moderately active, left sided ulcerative colitis. Am J Gastroenterol 1993 88 640-645. 

Mesalamine (5-aminosalicylic acid asacol, others) is a salicylate that is used for its local effects in the treatment of inflammatory bowel disease (see Chapter 38). It currently is available as a suppository and rectal suspension enema (rowasa) for treatment of mild-to-moderate proctosigmoiditis Cl rectal suppository (canasa, others) for the treatment of distal ulcerative colitis, proctosigmoiditis, or proctitis. Oral formulations and controlled-release capsule that deliver drug to the lower intestine are efficacious in treatment of inflammatory bowel disease, in particular ulcerative colitis. Sulfasalazine (salicylazosulfapyridine azulfidine) contains mesalamine linked covalently to sulfapyridine (see Chapter 38) it is absorbed poorly after oral administration, but it is cleaved to its active components by bacteria in the colon. The drug is of benefit in the treatment of inflammatory bowel disease, principally because of the local actions of mesalamine. 

Topical preparations of mesalamine suspended in a wax matrix suppository (rowasa) or in a suspension enema (canasa) are effective in active proctitis and distal ulcerative colitis, respectively. They appear to be superior to topical hydrocortisone in this setting, with response rates of 75-90%. Mesalamine enemas (4 g/60 mL) should be used at bedtime and retained for at least 8 hours the suppository (500 mg) should be used two to three times a day with the objective of retaining it for at least 3 hours. Response to local therapy with mesalamine may occur within 3-21 days however, the usual course of therapy is from 3-6 weeks. Once remission has occurred, lower doses are used for maintenance. 

Hydrocortisone is used (i) orally for replacement therapy (ii) imra-venousiy in shock and status asihmaiieus and (lit) topicaJly (e.g. ointments in eczema, enema.s in ulcerative colitis). 

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