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Medical Edge Newspaper Column from Mayo Clinic
MANY NEW TREATMENT OPTIONS FOR ULCERATIVE COLITIS
DEAR MAYO CLINIC: I am 51 and have recently been diagnosed with severe
ulcerative colitis. My entire colon is affected. I have probably had the
disease for several years. Please tell me about treatment options and
available clinical trials. — Michigan
ANSWER: Ulcerative colitis is a chronic inflammation of the innermost
lining of the large intestine (colon) and rectum — the tissue looks like
it was scraped by sandpaper. This condition provokes abdominal pain, diarrhea,
blood in the stools, the frequent (and often urgent) need to have a bowel
movement — even during sleep — and other symptoms. Ulcerative colitis
afflicts more than 700,000 Americans.
The disease’s cause remains unknown, though we suspect that the immune
system is a major factor, with the inflammation being an abnormal response
to normal intestinal contents. Heredity is also a factor — 15 percent
of patients have a close relative with the disease — as is environment:
It occurs more often in people who live in cities and industrialized nations.
While stress can be high in such locales, researchers no longer believe
that stress actually causes ulcerative colitis, though it can aggravate
pre-existing symptoms.
The disease is rarely fatal, but over time it carries a higher risk of
colon cancer (after 10 years, that risk can increase by as much as 1 percent
per year) and other serious complications. Physicians advise close monitoring
of the patient over the long term — for example, through regularly scheduled
colonoscopies.
My usual first-line treatment for ulcerative colitis is to try to reduce
the underlying inflammation with anti-inflammatory drugs such as sulfasalazine,
mesalamine, balsalazide or olsalazine — members of a class of medications
(5-ASA) distantly related to aspirin. If the patient is unresponsive,
I then move to steroids such as prednisone. Although prednisone is often
effective in the short term, it can be problematic in the long term, with
some patients experiencing flare-ups whenever the dose is tapered.
In such cases, the next step is to use medications — typically, azathioprine
or 6-mercaptopurine — that reduce inflammation indirectly by lessening
the body’s immune response. If these attempts prove insufficient, cyclosporine
is another option. In any case, patients receiving these immunosuppressive
agents need careful laboratory monitoring.
Some 20 percent of all ulcerative colitis patients ultimately require
surgery to remove the colon and rectum. This procedure actually cures
the disease, but has traditionally required an ostomy — an external appliance
for collecting waste. However, a surgical procedure championed by Mayo
Clinic and other referral centers, called ileoanal anastomosis, has eliminated
the need for a permanent ostomy by fashioning a “neo-rectum,” or “J-pouch,”
from the small intestine and attaching it to the anal sphincter.
Future options include novel investigational therapies that could displace
prednisone and other immunosuppressive drugs, and possibly avert the need
for surgery. Preliminary results from research on the drug infliximab
(Remicade) — a monoclonal antibody that targets an inflammation-producing
protein — appear promising.
In addition, scientists have developed an apheresis (blood-filtering)
procedure — a kind of mini-dialysis — to remove the activated white blood
cells that prompt the immune response. Finally, researchers are investigating
whether altering the natural balance of “good” and “bad” bacteria in the
intestine with probiotics can reduce the inflammatory response in the
colon.
Researchers often seek clinical-trials participants to study these and
other promising approaches. If you’re interested in learning more, a good
place to look is the Web site of the Crohn’s and Colitis Foundation of
America (www.ccfa.org), which allows you to search for trials in your
area.
— Edward V. Loftus Jr., M.D., Gastroenterology and Hepatology,
Mayo Clinic, Rochester, Minn.
Additional Resources:
Treatment
of Ulcerative Colitis
Appointment
Information
Research
Information
Additional
Information on Ulcerative Colitis
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Medical Edge from Mayo Clinic is an educational resource and doesn’t
replace regular medical care. To e-mail a question, go to www.mayoclinic.org,
or write: Medical Edge from Mayo Clinic, c/o TMS, 2225 Kenmore Ave., Suite
114, Buffalo, N.Y., 14207. For health information, visit www.mayoclinic.com.
© 2005 TRIBUNE MEDIA SERVICES, INC.
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