For ulcerative colitis, the recommended initial medication depends on the site and nature of the condition, but a topical aminosalicylate (suppositories, enema or rectal foam) would be the first choice.17
If there is no remission within four weeks, an oral aminosalicylate can be added (or substituted for the topical therapy using a high strength oral aminosalicylate) and if necessary, a time-limited topical or oral glucocorticoid, typically beclomethasone dipropionate (off-label usage). Treatment can be initiated with an oral aminosalicylate if necessary or with a topical or oral corticosteroid.
For moderate to severely active ulcerative colitis, NICE recommends several biologics – infliximab, adalimumab, golimumab, vedolizumab or tofacitinib – subject to its published technology appraisals.
People with acute severe ulcerative colitis and admitted to hospital may respond to intravenous corticosteroids or intravenous ciclosporin to induce remission, but surgery may also be considered. Adding ciclosporin may be necessary if there has been no response to steroids within 72 hours. Infliximab may be justified in circumstances where ciclosporin cannot be used.
For maintaining remission, a topical aminosalicylate alone and/or an oral aminosalicylate (both used daily or intermittently) can be used for mild to moderate ulcerative colitis. Oral aminosalicylate should be used for left-sided and extensive ulcerative colitis.
Oral azathioprine or oral mercaptopurine may be the preferred options to maintain remission if there have been two or more inflammatory exacerbations that have required systemic corticosteroids in the past year, or if remission cannot be maintained with aminosalicylates.