Ulcerative colitis is a chronic, inflammatory bowel disease that can be managed well with lifestyle changes and medication. Although the exact causes of the condition are not known, it is often associated with a recent infection from certain types of bacteria. The treatment for ulcerative colitis can involve a variety of medications meant to induce remission of symptoms and prevent a relapse. Locally applied medications have been shown to be effective for the majority of patients at promoting a relapse of symptoms. A compounding pharmacy can make unique dosages forms and combinations of ingredients for treating ulcerative colitis that are not commercially available.

Types of Ulcerative Colitis

Ulcerative colitis can be divided into three types based on the extent of the inflammation. If the condition is limited to the rectum, it is called ulcerative proctitis. This type is really an early-stage ulcerative colitis. If the symptoms extend further into the descending colon it is called left-sided ulcerative colitis. If the right side of the colon towards the appendix is affected it is called ulcerative pan-colitis. Suppositories are usually the most beneficial for cases of ulcerative proctitis, but they have also been used successfully to treat left-sided colitis. A suppository may be preferable for ulcerative proctitis because its effects are more limited to the rectal area. Enemas may be useful for both ulcerative proctitis and left-sided colitis, and is preferable when the inflammation reaches further into the colon.

Rectal Administration

Rectal administration can be beneficial because the medication is applied directly to the area being treated. When taken orally, a medication like mesalamine needs to be prevented from being released until it reaches the colon. This is not an issue when it is applied in an enema or suppository. Studies have shown that rectal administration with mesalamine is more effective, even though many patients are started on oral treatment first. In many cases a local medication is more effective than an oral medication for treating ulcerative colitis. Most healthcare providers will recommend a first-line treatment that is rectally administered for mild to moderate ulcerative colitis.

Mesalamine and Budesonide

The two main types of medications that are used for treating ulcerative colitis are 5-aminosalicylates and corticosteroids. Mesalamine, also called 5-aminosalicylic acid, is one of the primary treatments used for managing ulcerative colitis. This medication is applied rectally and always acts locally. Even if you take mesalamine orally, its effects are still local and not systemic. The medication will only reduce symptoms when it is allowed to come into contact with the inflamed parts of the colon.

Budesonide and hydrocortisone are steroidal medications that can be used as topical treatments for ulcerative colitis. While some healthcare providers will try either a 5-aminosalicylate or corticosteroid first, the two types of medications may also be combined. Some evidence shows that the combination of mesalamine and budesonide together may be more effective than each used alone.

Oral corticosteroids are also effective, but many patients would prefer to avoid this administration method due to an increased risk of systemic effects. If rectal administration of mesalamine does not produce any remission, oral corticosteroids may be prescribed.

Ulcerative Colitis and the Immune System

The inflammation of ulcerative colitis is thought to be related to an overactive immune response. Immune system modulators are prescribed as a way to reduce the responses in the body that cause inflammation of the colorectal area. There are a several immune system modifiers that are commonly used including azathioprine, 6-mercaptopurine, cyclosporine, and tacrolimus. These medications are usually not first-line treatments because of their potential side effects, including the possibility that they will reduce the body’s ability to fight infections. All of these medications are available commercially.

The biologic infliximab, called a “chimeric monoclonal antibody,” is used for treating various autoimmune diseases. This drug may be effective at treating ulcerative colitis but it is significantly more expensive than other treatments and has a higher incidence of adverse effects. Infections and re-activation of dormant viruses can potentially occur. In general this drug should be reserved only for more severe cases.

Experimental and Emerging Treatments

Short chain fatty acid enemas are enemas containing essential fatty acids that are naturally found in a healthy colon. These are increasingly being used by naturopathic doctors who have patients that do not want to use stronger medications. Since these fatty acids are found in decreased levels in patients with inflammatory bowel diseases, it is thought that replenishing them with an enema may help achieve remission of symptoms. Small-scale studies have shown that these enemas are effective but there have not been larger-scale clinical trials. While the research on SCFA enemas for ulcerative colitis is not conclusive, the treatment is still promising and warrants further exploration.

Low dose naltrexone is another promising therapy that may be useful as a non-toxic, affordable treatment for ulcerative colitis. This therapy involves taking a low dose of the FDA-approved drug naltrexone once daily. The FDA-approved version is used for helping individuals withdraw from opioid addictions. The dose used for ulcerative colitis is about 10x smaller than the FDA-approved dose. A recent study in the Journal of Translational Medicine concluded: “Naltrexone directly improves epithelial barrier function by improving wound healing and reducing mucosal ER stress levels. Low dose Naltrexone treatment is effective and safe, and could be considered for the treatment of therapy refractory IBD patients.”

Other Prescription and Over-the-Counter Treatments

Other medications may also be prescribed for targeting more specific symptoms of colitis. For example, anti-diarrheals and pain medications may be used to provide immediate relief until there is a more significant remission in symptoms. Often these medications can be purchased over-the-counter. Ulcerative colitis is also associated with an increased risk of infection that may need to be treated with antibiotics. Other nutritional supplements may be recommended by a healthcare provider to help the body naturally fight inflammation and maintain good overall health.

Available from Our Compounding Pharmacy

At Park Compounding Pharmacy, we make several compounded treatments for ulcerative colitis. These include:

• Mesalamine 500mg or 1000mg Suppositories
• Mesalamine 500mg, Budesonide 6mg Suppositories
• Short Chain Fatty Acid Enemas with Sodium Acetate, Sodium Propionate, and Sodium Butyrate
• Sodium Butyrate 11mg/mL, Budesonide 0.02mg/mL Enemas
• Low Dose Naltrexone 1.5mg to 4.5mg

Managing Ulcerative Colitis

Staying with a prescribed treatment is essential as it can take time to achieve remission. However, achieving remission often requires more than just strict adherence to a medication regimen. Dietary changes and careful attention to potential triggers of flare-ups, in combination with prescription treatments, can help many patients get their symptoms under control.

Research

• Randomised clinical trial: evaluation of the efficacy of mesalazine (mesalamine) suppositories in patients with ulcerative colitis and active rectal inflammation – a placebo‐controlled study – Alimentary Pharmacology and Therapeutics (Wiley Online Library)
• Comparison of oral with rectal mesalazine in the treatment of ulcerative proctitis.- Diseases of the Colon and Rectum – Diseases of the Colon and Rectum (PubMed)
• Treatment of refractory distal ulcerative colitis with short chain fatty acid enemas. – The American Journal of Gastroenterology (PubMed)
• Low dose naltrexone for induction of remission in inflammatory bowel disease patients. – Journal of Translational Medicine (PMC)