Ulcerative colitis
A chronic immune-mediated inflammation of colonic mucosa starting in the rectum and extending proximally. Symptoms: bloody diarrhea, tenesmus, abdominal pain, weight loss. ECCO 2024 and the Spanish GETECCU 2023 consensus tier therapy by severity and extent: mild proctitis – topical 5-ASA or steroids; extensive mild-to-moderate colitis – oral 5-ASA (sulfasalazine, mesalazine); severe – systemic steroids and immunomodulators (azathioprine); refractory or steroid-dependent – biologics (anti-TNFα, vedolizumab, ustekinumab) and JAK inhibitors (tofacitinib, upadacitinib).
Also known as: UC, Idiopathic ulcerative colitis
Drugs used for this condition
- AAdalimumabSecond line · Biologic – tumor necrosis factor alpha (TNFα) inhibitorBiologic for moderate-to-severe ulcerative colitis in patients with corticosteroid and immunomodulator (azathioprine, 6-mercaptopurine) failure or intolerance per ECCO 2022. Induction: 160 mg subcutaneously, then 80 mg at week 2, then 40 mg every 2 weeks. Less effective than infliximab in severe active colitis but more convenient via subcutaneous injection.
- AMesalazineFirst line · Locally acting intestinal aminosalicylateFirst-line for mild-to-moderate ulcerative colitis to induce and maintain remission per ECCO 2022 and the Spanish GETECCU 2023. Induction 2.4–4.8 g daily in 2–3 doses; maintenance 1.5–2.4 g daily. In distal colitis and proctitis, add enemas 4 g once daily or suppositories 1 g once daily. The 2020 Cochrane meta-analysis showed remission induction in 50–60% and 2–3-fold reduction in relapse risk.
- ASulfasalazineFirst line · Intestinal aminosalicylate and disease-modifying antirheumatic drug (DMARD)First-line for mild-to-moderate ulcerative colitis to induce and maintain remission per ECCO 2022 and the Spanish GETECCU 2023 consensus. Dose 2–4 g daily for induction; 2 g daily for maintenance. In patients intolerant to sulfonamides, pure 5-ASA agents (mesalazine, olsalazine) are preferred. Mostly used in mild colitis with distal involvement; severe disease requires systemic steroids and immunosuppressants.
- AUstekinumabSecond line · Biologic – interleukin-12 and -23 inhibitorSecond-line for moderate-to-severe ulcerative colitis per ECCO 2024. IV induction by weight, then 90 mg subcutaneously every 8–12 weeks.
How to read tiers A–F
Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.
- AStrong evidence – first or second line in international guidelines
- BRecommended in selected cases
- CStudy data contradict each other
- DBenefit not proven, no documented harm
- FDocumented harm, or risk without benefit