Ulcerative Colitis Clinical Case Review

Eugenia Uche-Anya, MD, MPH, gastroenterology fellow at Massachusetts General Hospital, discusses the results of the case and important points to keep in mind when treating patients with mild UC:

"Given resolution of his symptoms, he underwent a repeat colonoscopy in six months. The entire examined colon appeared normal to the terminal ileum with known scattered diverticula noted.

Here, we have a summary of the AGA guidelines for the management of mild to moderate ulcerative colitis. Randomized control trials comparing rectal to oral mesalamine for mild ulcerative proctitis or proctosigmoiditis show that mesalamine enemas may be more effective than low dose oral mesalamine, that as doses less than two grams a day in inducing and maintaining remission. Meta analyses have also shown that topical mesalamine is more effective than topical corticosteroids and inducing remission.

For this reason, topical mesalamine is first line, while rectal corticosteroids can be used in patients who are intolerant of mesalamine due to adverse effects, for example. For topical preparations enemas are preferred as preparations reach the splenic flexure as opposed to forms which only reach the mid sigmoid colon. Patients may have a preference against rectally administering medications and may prefer oral therapy instead.

According to AGA guidelines, oral mesalamine is a reasonable option for patients who have this preference. Multiple randomized control trials, comparing mesalamine to placebo for patients with extensive, mild to moderate ulcerative colitis have shown that standard doses, that as two to three grams a day and high doses, that as greater than three grams a day of mesalamine were affected for inducing remission, while standard doses and lower doses were affected for maintenance of remission.

In refractory cases, topical mesalamine can be added to oral mesalamine. If this fails, budesonide or prednisone can be added. Budesonide is a high potency corticosteroid with low systemic activity due to extensive first pass metabolism by the liver. There are multiple studies showing that budesonide is superior to placebo for inducing remission. However, there are limited long-term efficacy or safety data for user budesonide for maintenance of remission, and as a result, it is not a preferred long-term agent, especially given the known adverse effects associated with long-term steroid use.

In our clinical vignette, the treatment was chosen via shared decision making with the patient. Though rectal mesalamine was the first line therapeutic agent for the patient given his clinical presentation, his preference to avoid rectally administered medication suggested that oral mesalamine was actually the better therapeutic choice for him. This likely led to better compliance with the medication, patient satisfaction, and a good clinical outcome. This illustrates the importance of shared decision making with patients when deciding therapeutic agents for their ulcerative colitis.

Thank you very much for joining me to review this case."