Ulcerative colitis moderate

Crohn s disease, rheumatoid arthritis Treatment of active to moderate ulcerative colitis, proctosigmoiditis, or proctitis... 

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. 

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... 

Gionchetti P, Rizzello F, Ferrieri A, Venturi A, Brignola C, Ferretti M, Peruzzo S, Miglioli M, Campieri M Rifaximin in patients with moderate or severe ulcerative colitis refractory to steroid-treatment A double-blind, placebo-controlled trial. Dig Dis Sci 1999 44 1220-1221. 

An increasing number of both clinical and laboratory-derived observations support the importance of luminal components in driving the inflammatory response in ulcerative colitis and Crohn s disease. Although its role is unclear, antibiotic therapy is commonly used in clinical practice for the treatment of moderately to severely active ulcerative colitis. Metronidazole and/or ciprofloxacin are currently employed in active Crohn s disease, particularly in patients with colonic involvement and with perianal disease. Rifaximin, a rifamycin-derived antibiotic, is characterized by a wide range of antibacterial activity and a very low systemic absorption. Some preliminary data show its efficacy in severe active ulcerative colitis, pouchitis and prevention of postoperative recurrence in Crohn s disease. 

Lukas M, Konecny M, Zboril V Rifaximin in patients with mild to moderate activity of ulcerative colitis An open label study. Gastroenterology 2002 122(suppl 1) A434. 

Corticosteroids and adrenocorticotropic hormone have been widely used for the treatment of ulcerative colitis and Crohn s disease and are used in moderate to severe disease. Prednisone is most commonly used. Budesonide is an oral controlled-release formulation that minimizes systemic effects. 

Steroids have a place in the treatment of moderate to severe ulcerative colitis that is unresponsive to maximal doses of oral and topical mesalamine. Prednisone up to 1 mg/kg/day or 40 to 60 mg daily may be used for patients who do not have an adequate response to sulfasalazine or mesalamine. 

Transdermal nicotine improved symptoms of patients with mild to moderate active ulcerative colitis in daily doses of 15 to 25 mg. 

Ulcerative colitis In the treatment of mild to moderate ulcerative colitis, and as adjunctive therapy in severe ulcerative colitis for the prolongation of the remission period between acute attacks of ulcerative colitis (refer to the sulfasalazine monograph in the Gl chapter). 

Oral - Remission and treatment of mildly to moderately active ulcerative colitis. 

Sulfasalazine treatment results in an 85% remission rate in mild to moderate ulcerative colitis. Termination of therapy leads to an 80% relapse within the next year. In Crohn s disease, sulfasalazine acts primarily on involved colonic mucosa, although remission of ileal disease also has been reported. The National Cooperative Crohn s Disease Study found sulfasalazine to be better in the treatment of colonic disease, while corticosteroids were judged better in the treatment of small bowel disease. Since sulfasalazine does not prevent relapse of Crohn s disease once remission is achieved, maintenance therapy is not characteristically used. 

Olsalazine sodium (Dipentum) links two 5-ASA molecules with an azo linkage. Following cleavage of the azo linkage in the colon, two 5-ASA molecules are released. Olsalazine is approved for maintenance of remission of ulcerative colitis, but a commonly reported side effect is a paradoxical increase in diarrhea. The U. S. Food and Drug Administration (FDA) has approved balsalazide disodium (Colazal) as a treatment of mild to moderately active ulcerative colitis. Balsalazide... 

C. The information provided suggests the patient has mild to moderate disease. Initial therapy should be a 5-ASA containing product, which includes sulfasalazine and mesalamine. However, the patient has a sulfa allergy, precluding the use of sulfasalazine. Metronidazole is useful in the treatment of some patients with Crohn s disease. Cyclosporine has been used in patients with fulminant ulcerative colitis. Prednisone may have to be added to this patient s therapy, but only if he fails to respond to the mesalamine. It should not be used initially. 

Crohn s disease, moderate to severe, ulcerative colitis, psoriatic arthritis IV Infusion... 

Therapeutic pyramid approach to inflammatory bowel diseases. Treatment choice is predicated on both the severity of the illness and the responsiveness to therapy. Agents at the bottom of the pyramid are less efficacious but carry a lower risk of serious adverse effects. Drugs may be used alone or in various combinations. Patients with mild disease may be treated with 5-aminosalicylates (with ulcerative colitis or Crohn s colitis), topical corticosteroids (ulcerative colitis), antibiotics (Crohn s colitis or Crohn s perianal disease), or budesonide (Crohn s ileitis). Patients with moderate disease or patients who fail initial therapy for mild disease may be treated with oral corticosteroids to promote disease remission immunomodulators (azathioprine, mercaptopurine, methotrexate) to promote or maintain disease remission or anti-TNF antibodies. Patients with moderate disease who fail other therapies or patients with severe disease may require intravenous corticosteroids, anti-TNF antibodies, or surgery. Natalizumab is reserved for patients with severe Crohn s disease who have failed immunomodulators and TNF antagonists. Cyclosporine is used primarily for patients with severe ulcerative colitis who have failed a course of intravenous corticosteroids. TNF, tumor necrosis factor. 

ASA drugs induce and maintain remission in ulcerative colitis and are considered to be the first-line agents for treatment of mild to moderate active ulcerative colitis. Their efficacy in Crohn s disease is unproven, although many clinicians use 5-ASA agents as first-line therapy for mild to moderate disease involving the colon or distal ileum. 

Infliximab is approved for the treatment of patients with moderate to severe ulcerative colitis who have had inadequate response to mesalamine or corticosteroids. After induction therapy of 5-10 mg/wk at 0, 2, and 6 weeks, 70% of patients have a clinical response and one third achieve a clinical remission. With continued maintenance infusions every 8 weeks, approximately 50% of patients have continued clinical response. 

Aminosalicylates, eg, mesalamine in many formulations Mechanism uncertain t may be inhibition of eicosanoid inflammatory mediators Topical therapeutic action systemic absorption may cause toxicity Mild to moderately severe Crohn s disease and ulcerative colitis Sulfasalazine causes sulfonamide toxicity and may cause GI upset, myalgias, arthralgias, myelosuppression other aminosalicylates much less toxic... 

Purine analogs and antimetabolites, eg, 6-mercaptopurine, methotrexate Mechanism uncertain may promote apoptosis of immune cells Generalized suppression of immune processes Moderately severe to severe Crohn s disease and ulcerative colitis GI upset, mucositis myelosuppression purine analogs may cause hepatotoxicity, but rare with methotrexate at the low doses used... 

Anti-TNF antibodies, eg, infliximab, others Bind tumor necrosis factor and prevent it from binding to its receptors Suppression of several aspects of immune function, especially ThI lymphocytes Infliximab Moderately severe to severe Crohn s disease and ulcerative colitis others approved in Crohn s disease Infusion reactions reactivation of latent tuberculosis increased risk of dangerous systemic fungal and bacterial infections... 

Pulsed glucocorticoid therapy for moderately severe ulcerative colitis, given on an out-patient basis, can induce remission more quickly than conventional oral glucocorticoid therapy (421). There were no serious adverse effects in 11 patients given pulsed glucocorticoids or in eight treated conventionally. The two regimens were equally efficacious. 

Oshitani N, Kamata N, Ooiso R, Kawashima D, Inagawa M, Sogawa M, Iimuro M, Jinno Y, Watanabe K, Higuchi K, Matsumoto T, Arakawa T. Outpatient treatment of moderately severe active ulcerative colitis with pulsed steroid therapy and conventional steroid therapy. Dig Dis Sci 2003 4 1002-5. 

Mesalazine has only been shown to be of benefit in mild to moderate flares of ulcerative colitis and so it can be stopped. It is unlikely to be absorbed. 

Sulfasalazine is also licensed for treatment of mild to moderate and severe ulcerative colitis and maintenance of remission, and active Crohn s disease. 

Systemic corticosteroid. Moderately severe attacks of ulcerative colitis should be treated with systemic corticosteroid, and oral preparations usually suffice. It is important to give enough drug to bring the inflammatory process under control (starting dose... 

In a 12-week trial in 168 patients with mild to moderate ulcerative colitis, olsalazine 3 g/day was as effective as mesalazine 3 g/day in inducing a remission (5). There were more adverse effects in patients taking olsalazine (41 of 88) than mesalazine (29 of 80). Most of the adverse effects related to bowel disturbances diarrhea, vomiting, abdominal discomfort, heartburn, flatulence, and nausea. Diarrhea was more common in patients taking olsalazine. One patient taking mesalazine developed a lupus-like syndrome. 

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. 

Nephrotoxicity has been described during treatment with olsalazine (SEDA-21, 364). To assess the effects of 9 months of treatment with oral mesalazine 1.2 g/day and olsalazine 1 g/day on renal function, a randomized trial has been performed in 40 patients with ulcerative colitis in complete remission (91). Neither drug had a significant effect on glomerular filtration rate. Adverse effects (all mild to moderate) were more common in the mesalazine group they included abdominal pain and distension, dyspepsia, nausea, and diarrhea. 

The use of oral enteric-coated mesalazine, which releases mesalazine in the terminal ileum and colon, has been reviewed (88,100). Dose-related improvements in clinical and endoscopic parameters have been reported with prolonged-release mesalazine 1-A g/day in trials in patients with mild to moderately active ulcerative colitis. About 74% of patients with mild to moderate ulcerative colitis improve with enteric-coated mesalazine 2.4. 8 g/ day. There is a trend toward a better response with higher doses. Oral enteric-coated mesalazine 0.8-4.4 g/day appears to be as effective as sulfasalazine 2-4 g/day, modified-release mesalazine 1.5 g/day, and balsalazide 3 g/day in maintaining remission in ulcerative colitis. 

In a randomized, open trial in 227 patients with mild to moderate ulcerative colitis, mesalazine 4 g/day given as prolonged-release granules bd and qds was as effective as prolonged-release tablets given qds (101). All the treatments were well tolerated and the frequencies of adverse effects were similar in the treatment groups. The patients preferred twice-daily dosing. 

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