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Ulcerative Colitis
Dr.Siddharth Singh
Classification into severe UC
● Maintenance therapy:
5-aminosalicylates:topical,oral and combination
Azathioprine and 6-MP
Infliximab or adalimumab
5-AMINOSALICYLATES
● Sulphasalazine- 5-ASA is the principal therapeutic moeity and
sulfapyridine is carrier(so it gets absorbed in colon)
● Has not been proved in any tests to provide remission in severe UC but
can be used for maintenance once remission achieved.
● 5-ASA has dose dependent effect in maintenance therapy(2g/day)
● Other preparations:Olsalazine,Balsalazide and Mesalamine
preparations(these other drugs have similar efficacy as 5 – ASA but their
role in maintenance therapy is still under evaluation)
● Side effects:fever ,rash ,nausea , vomiting and headache.Less common
are hypersenstivity,folate deficiency and AKI.
● Topical formulations:Enemas(Upto splenic flexure),Suppositiries(!5-20cm
from anal verge) and foam preparations.
Glucocorticoids
● Use upto 60mg/day,above this S/E>benefit
● Oral vs parenteral:no study but latter preferred for severe UC
● No maintenance benefits; if unable to taper prefer steroid sparing agents
● Regimens for intravenous steroids include prednisolone (30 mg IV every 12
hours), methylprednisolone (16 to 20 mg IV every eight hours), or
hydrocortisone (100 mg IV every eight hours) In patients who respond,
intravenous glucocorticoids should be converted to equivalent dose of oral
glucocorticoids in three to five days.
● Oral glucocorticoids should be tapered after the patient has been stable for
two to four weeks. Oral glucocorticoids should be tapered over eight weeks
by decreasing the dose by 5 to 10 mg every week until a daily dose of 20
mg is reached, and then by 2.5 mg every week
● Budesonide can be used less toxicity due to
high first pass metabolism by Liver and RBCs
into active metabolites
● TOPICAL: liquid and foam formulations;foams
very well tolerated by patients
Prolonged treatment with topical also related to
steroid related side effects
IMMUNOMODULATORS
● Azathioprine and 6-MP:
Purine analogs,Steroid sparing,Prodrugs
● Azathioprine undergoes nonenzymatic
degradation to 6-MP which is metabolized into
a)6-TG which is the active metabolite
b)6-MP/6-MMP:by enzyme TPMT which are
responsible for the myelotoxicity and
hepatotoxicity
● Population polymorphism in TPMT gene
● Take 3-6 months for response so cannot be used as
monotherapy in severe UC
● If contnue mantain remisson whereas on stopping
risk of relapse is high , so maintenance indefinitely
● Side effects:Increase dose gradually and monitor
A)Aminotransferases:>50% increase then stop till
normalise and then reintroduce at low dose;but if
Bilirubin high dont
B)TC<3000 or Platelets<80000 then stop and
reintroduce on normalisation
● LYMPHOMA:especially if persistent leucopenia,
most common-Non hodgkins; Hepatosplenic T cell
lymphoma
● DEFINITIONS — The following definitions of ulcerative colitis have
been proposed :