Treatment
Treatment for ulcerative colitis depends on how severe the condition is and how often your symptoms flare-up.
The main aims of treatment are to:
- reduce symptoms, known as inducing remission (a period without symptoms)
- maintain remission
This usually involves taking various types of medicine, although surgery may sometimes be an option.
Your treatment will normally be provided by a range of healthcare professionals, including:
- specialist doctors, such as gastroenterologists or surgeons
- GPs
- specialist nurses
Your care will often be co-ordinated by your specialist nurse and your care team, and they'll usually be your main point of contact if you need help and advice.
Aminosalicylates
Aminosalicylates, also known as 5-ASAs, are medicines that help to reduce inflammation. This in turn allows damaged tissue to heal.
They're usually the first treatment option for mild or moderate ulcerative colitis.
5-ASAs can be used as a short-term treatment for flare-ups. They can also be taken long term, usually for the rest of your life, to maintain remission.
5-ASAs can be taken:
- orally – by swallowing a tablet or capsule
- as a suppository – a capsule that you insert into your bottom (rectum), where it dissolves
- through an enema – where fluid is pumped into your large intestine
How you take 5-ASAs depends on the severity and extent of your condition.
If you have mild-to-moderate ulcerative colitis, you'll usually be offered a 5-ASA to take in suppository or enema form.
If your symptoms do not improve after 4 weeks, you may be advised to take 5-ASA in tablet or capsule form as well.
These medicines rarely have side effects, but some people may experience:
Corticosteroids
Corticosteroids, such as prednisolone, are an alternative type of medicine used to reduce inflammation.
They can be used with or instead of 5-ASAs to treat a flare-up if 5-ASAs alone are not effective.
Like 5-ASAs, steroids can be administered orally, or through a suppository or enema.
But unlike 5-ASAs, corticosteroids are not used as a long-term treatment to maintain remission because they can cause potentially serious side effects, such as weakening of the bones (osteoporosis) and cloudy patches in the lens of the eye (cataracts), when used for a long time.
Side effects of short-term steroid use can include:
- acne
- weight gain
- increased appetite
- mood changes, such as becoming more irritable
- difficulty sleeping (insomnia)
Immunosuppressants
Immunosuppressants, such as tacrolimus and azathioprine, are medicines that reduce the activity of the immune system.
They're usually given as tablets to treat mild or moderate flare-ups, or maintain remission if your symptoms have not responded to other medicines.
Immunosuppressants can be very effective in treating ulcerative colitis, but they may take a while to start working.
The medicines can make you more vulnerable to infection, so it's important to report any signs of infection, such as a high temperature or sickness, promptly to a GP.
They can also lower the production of red blood cells, making you prone to anaemia.
You'll need regular blood tests to monitor your blood cell levels and check for any other problems.
Treating severe flare-ups
While mild or moderate flare-ups can usually be treated at home, more severe flare-ups should be managed in hospital to minimise the risk of dehydration and potentially fatal complications, such as your colon rupturing.
In hospital, you'll be given medicine and sometimes fluids directly into a vein (intravenously).
The medicines you have will usually be a type of corticosteroid or an immunosuppressant medicine called infliximab or ciclosporin.
Ciclosporin
Ciclosporin is given slowly through a drip in your arm (an infusion) and treatment will usually be continuous, for around 7 days.
Side effects of intravenous ciclosporin can include:
- an uncontrollable shaking or trembling of part of the body (a tremor)
- excessive hair growth
- extreme tiredness (fatigue)
- swollen gums
- feeling and being sick
- diarrhoea
Ciclosporin can also cause high blood pressure and reduced kidney and liver function, but you'll be monitored regularly during treatment to check for signs of these.
Biologic medicines
Biologic medicines are medicines that reduce inflammation of the intestine by targeting proteins the immune system uses to stimulate inflammation.
These medicines block these receptors and reduce inflammation.
They may be used to treat moderate to severe ulcerative colitis if other options are not suitable or not working.
Biologic medicines are given in hospital as an infusion through a drip in your arm every 4 to 12 weeks, or as an injection every 1 to 4 weeks.
Your treatment team will then see how you respond to treatment. If your symptoms are under control (remission) for a year or more, they may recommend treatment is stopped.
Biologic medicines affect your immune system and can increase your risk of getting infections. Talk to a GP if you have any symptoms of a possible infection, such as coughs, a high temperature or a sore throat.
Find out more about biologic medicines from Crohn's & Colitis UK
JAK inhibitors
There are now new types of medicines called JAK inhibitors, such as tofacitinib and filgotinib, that can be used to treat ulcerative colitis.
These work by blocking enzymes (proteins) that the immune system uses to trigger inflammation.
JAK inhibitors can be taken as tablets.
JAK inhibitors may be recommended for people with moderate to severe ulcerative colitis if standard treatments or biologics have not worked, or are not suitable.
JAK inhibitors are not recommended for use in pregnancy. Women should use reliable contraception when taking them, at for at least 4 weeks after finishing the course.
Surgery
If you have frequent flare-ups that have a significant effect on your quality of life, or you have a particularly severe flare-up that's not responding to medicines, surgery may be an option.
Surgery for ulcerative colitis involves permanently removing the colon (a colectomy).
Once your colon is removed, your small intestine will be used to pass waste products out of your body instead of your colon.
This can be achieved by creating:
- an ileostomy – where the small intestine is diverted out of a hole made in your tummy; special bags are placed over this opening to collect waste materials after the operation
- an ileoanal pouch (also known as a J-pouch) – where part of the small intestine is used to create an internal pouch that's then connected to your anus, allowing you to poo normally
As the colon is removed, ulcerative colitis cannot come back again after surgery.
But it's important to consider the risks of surgery and the impact of having a permanent ileostomy or ileoanal pouch.
Your healthcare team will discuss the best option with you.
Find out more about ileostomies and ileoanal pouches
Help and support
Living with a condition like ulcerative colitis, especially if your symptoms are severe, can be a frustrating and isolating experience.
Talking to others with the condition can provide support and comfort.
Crohn's and Colitis UK provides information on where you can find help and support.
Living with
There are some things you can do to help keep symptoms of ulcerative colitis under control and reduce your risk of complications.
Dietary advice
Although a specific diet is not thought to play a role in causing ulcerative colitis, some changes to your diet can help control the condition.
For example, you may find it useful to:
- eat small meals – eating more frequent smaller meals a day, rather than 3 main meals, may help control your symptoms
- drink plenty of fluids – it's easy to become dehydrated when you have ulcerative colitis, as you can lose a lot of fluid through diarrhoea; water is the best source of fluids, and you should avoid caffeine and alcohol, as these will make your diarrhoea worse, and fizzy drinks, which can cause flatulence (gas)
- take food supplements – ask your GP or gastroenterologist if you need food supplements, as you might not be getting enough vitamins and minerals in your diet
Keep a food diary
Keeping a food diary that documents what you eat can also be helpful.
You may find you can tolerate some foods while others make your symptoms worse.
By keeping a record of what and when you eat, you should be able to identify problem foods and eliminate them from your diet.
But you should not eliminate entire food groups (such as dairy products) from your diet without speaking to your care team, as you may not get enough of certain vitamins and minerals.
If you want to try a new food, it's best to only try 1 type a day because it's then easier to spot foods that cause problems.
Low-residue diet
Temporarily eating a low-residue or low-fibre diet can sometimes help improve symptoms of ulcerative colitis during a flare-up.
These diets are designed to reduce the amount and frequency of the stools you pass.
Examples of foods that can be eaten as part of a low-residue diet include:
- white bread
- refined (non-wholegrain) breakfast cereals, such as cornflakes
- white rice, refined (low-fibre) pasta and noodles
- cooked vegetables (but not the peel, seeds or stalks)
- lean meat and fish
- eggs
If you're considering trying a low-residue diet, make sure you talk to your care team first.
Stress relief
Although stress does not cause ulcerative colitis, successfully managing stress levels may reduce the frequency of symptoms.
The following advice may help:
- exercise – this has been proven to reduce stress and boost your mood; your GP or care team can advise on a suitable exercise plan
- relaxation techniques – breathing exercises, meditation and yoga are good ways of teaching yourself to relax
- communication – living with ulcerative colitis can be frustrating and isolating; talking to others with the condition can help
Emotional impact
Living with a long-term condition that's as unpredictable and potentially debilitating as ulcerative colitis can have a significant emotional impact.
In some cases, anxiety and stress caused by ulcerative colitis can lead to depression.
Signs of depression include feeling very down, hopeless and no longer taking pleasure in activities you used to enjoy.
If you think you might be depressed, contact your GP for advice.
You may also find it useful to talk to others affected by ulcerative colitis, either face-to-face or via the internet.
Crohn's and Colitis UK is a good resource, with details of local support groups and a large range of useful information on ulcerative colitis and related issues.
Fertility
The chances of a woman with ulcerative colitis becoming pregnant are not usually affected by the condition.
But infertility can be a complication of surgery carried out to create an ileo-anal pouch.
This risk is much lower if you have surgery to divert the small intestine through an opening in your abdomen (an ileostomy).
Pregnancy
The majority of women with ulcerative colitis who decide to have children will have a normal pregnancy and a healthy baby.
But if you're pregnant or planning a pregnancy, you should discuss it with your care team.
If you become pregnant during a flare-up or have a flare-up while pregnant, there's a risk you could give birth early (premature birth) or have a baby with a low birthweight.
For this reason, doctors usually recommend trying to get ulcerative colitis under control before getting pregnant.
Most ulcerative colitis medicines can be taken during pregnancy, including corticosteroids, most 5-ASAs and some types of immunosuppressant medicine.
But there are certain medicines, such as some types of immunosuppressant, that may need to be avoided as they're associated with an increased risk of birth defects.
In some cases, your doctors may advise you to take a medicine that's not normally recommended during pregnancy.
This might happen if they think the risks of having a flare-up outweigh the risks associated with the medicine.
Complications
If you have ulcerative colitis, you could develop further problems.
Extra-intestinal manifestations
Around 1 in 3 people with ulcerative colitis will also develop inflammation in other parts of their body. This can lead to a range of symptoms that doctors call extra-intestinal manifestations, or extra-intestinal symptoms.
These include:
- pain, swelling and stiffness of the joints – which usually happens in larger joints, such as the ankles, knees, hips and wrist
- tender bumps can appear on the skin – usually on the arms and legs
- painful mouth ulcers
- eyes can become red, irritated and itchy
Osteoporosis
People with ulcerative colitis are at an increased risk of developing osteoporosis, when the bones become weak and are more likely to fracture.
Osteoporosis can happen due to a number of factors, such as side effects of steroid medicines and the body having problems absorbing the nutrients it needs for bone growth.
It can also be caused by the dietary changes someone with the condition may take, such as avoiding dairy products, if they believe it could be triggering their symptoms.
If you're thought to be at risk of osteoporosis, the health of your bones will be regularly monitored.
You may also be advised to take medicine or supplements of vitamin D and calcium to strengthen your bones.
Poor growth and development
Ulcerative colitis, and some of the treatments for it, can affect growth and delay puberty.
Children and young people with ulcerative colitis should have their height and body weight measured regularly by healthcare professionals.
This should be checked against average measurements for their age.
If there are problems with your child's growth or development, they may be referred to a paediatrician (a specialist in treating children and young people).
Primary sclerosing cholangitis
Some people with ulcerative colitis may also develop another digestive condition called primary sclerosing cholangitis (PSC). PSC is where the bile ducts become progressively inflamed and damaged.
Bile ducts are small tubes used to transport bile (digestive juice) out of the liver and into the digestive system.
PSC does not usually cause symptoms until it's at an advanced stage.
Symptoms can include:
- fatigue (extreme tiredness)
- diarrhoea
- itchy skin
- weight loss
- chills
- a high temperature
- yellowing of the skin and the whites of the eyes (jaundice)
There's currently no specific treatment for PSC, although medicines can be used to relieve some of the symptoms, such as itchy skin.
In more severe cases, a liver transplant may be required.
Toxic megacolon
Toxic megacolon is a rare and serious complication of severe ulcerative colitis where inflammation in the colon causes gas to become trapped, resulting in the colon becoming enlarged and swollen.
This is potentially very dangerous as it can cause the colon to rupture (split) and cause infection in the blood (septicaemia).
The symptoms of a toxic megacolon include:
- tummy pain
- a high temperature
- a rapid heart rate
Toxic megacolon can be treated with fluids, antibiotics and steroids given directly into a vein (intravenously).
If medicines do not improve the conditions quickly, surgical removal of the colon (a colectomy) may be needed.
Treating symptoms of ulcerative colitis before they become severe can help prevent toxic megacolon.
Bowel cancer
People who have ulcerative colitis have an increased risk of developing bowel cancer (cancer of the colon, rectum or bowel), especially if the condition is severe or involves most of the colon.
The longer you have ulcerative colitis, the greater the risk.
People with ulcerative colitis are often unaware they have bowel cancer as the initial symptoms of this type of cancer are similar.
These include:
- blood in your poo
- diarrhoea
- abdominal pain
You'll usually have regular check-ups to look for signs of bowel cancer from about 10 years after your symptoms first develop.
Check-ups will involve examining your bowel with a colonoscope (a long, flexible tube containing a camera) that's inserted into your rectum – this is called a colonoscopy.
The frequency of the colonoscopy examinations will increase the longer you live with the condition, and will also depend on factors such as how severe your ulcerative colitis is and if you have a family history of bowel cancer.
This can vary between every 1 to 5 years.
To reduce the risk of bowel cancer, it's important to:
- eat a healthy, balanced diet including plenty of fresh fruit and vegetables
- take regular exercise
- maintain a healthy weight
- avoid alcohol and smoking
Taking aminosalicylates as prescribed can also help reduce your risk of bowel cancer.
Find out more about preventing bowel cancer