First Line Treatment Ulcerative Colitis

Ayurvedic Treatment Of Ulcerative Colitis

Ayurvedic treatment for Ulcerative Colitis is exceptionally effective. Its a combination of personalized herbal drugs, lifestyle, and diet plans combined with customized Ayurvedic home remedies for Ulcerative Colitis that addresses the root cause of the issue. The ayurvedic treatment provides an effective remedy for Ulcerative colitis based on the classical principle of Ayurveda. The treatment of Ulcerative colitis is typically centered on healing the ulcers, restoring the colons routine use, and maintaining the general health of the digestive tract.

The Ayurvedic holistic reatment entails Shamana chikitsa , Shodana chikitsa , lifestyle modifications, and quite a strict diet program. In more severe cases, Panchakarma treatment plays a crucial role as it quickly detoxifies & rejuvenates the digestive tract, controls the inflammation, rectal bleeding, and fixes the ulcerations. Usually, results are extremely good with the Ayurvedic line of treatment. Early cases tend to react quickly than chronic. If an individual can stick to all of the guidelines as advised, even complete treatment may also be achieved.

Connected with bleeding: At the intermediate phase, bleeding can be observed together with the other symptoms. Taking the new complications under consideration, the treatment at this point works primarily to cure the ulcer and decrease bleeding. Dietary restrictions, together with specific lifestyle guidelines, are suggested to minimize bleeding.

How Do Doctors Treat Ulcerative Colitis

Doctors treat ulcerative colitis with medicines and surgery. Each person experiences ulcerative colitis differently, and doctors recommend treatments based on how severe ulcerative colitis is and how much of the large intestine is affected. Doctors most often treat severe and fulminant ulcerative colitis in a hospital.

Maintenance Of Remission And Transition From Paediatric To Adult Care

Transition to adult services should be coordinated by paediatric and adult teams. It usually commences in mid adolescence, depending on the development of the patient and the availability of paediatric and adult gastroenterologists

Transition is successful when the patient has acquired the self-management skills to visit and talk to the doctor alone, understands disease management including risks and benefits, and is adherent to treatment

The optimal timing of transition from paediatric to adult management of UC has to be decided on an individual basis by a joint team of paediatric and adult gastroenterologists. The transition period usually starts from the age of 1618 years, depending on patient development and availability of qualified paediatric and adult gastroenterologists. This area has been addressed by an ECCO Topical Review.320

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Optimal Asuc Care Is Multidisciplinary In Nature

ASUC management requires early liaison with other medical specialities from the start of the admission with the multidisciplinary team consisting of a gastroenterologist specialised in IBD, an abdominal surgeon, a radiologist, the IBD nurse and a nutritionist.

Discussing the timing and advantages of surgery early on with the patient is important and requires not only the colorectal surgeon but an early intervention of the stoma nurse. Despite offering the prospect of a restored bowel function, IPAA in itself has a significant impact on functionality and quality of life. Frequently occurring complications such as leakage, sexual dysfunction, soiling and the occurrence of inflammatory disorders of the pouch in up to 50% of IPAA patients should be discussed upfront. Importantly, ileal pouch-anal anastomosis has profound effects on female fertility in a population often within the child-bearing age, although laparoscopic approaches tend to have less severe effects, presumably due to less intra-abdominal adhesions.54,55

Goal Of Maintenance Therapy

The goal of maintenance therapy in ulcerative colitis is to maintain steroid-free remission, defined clinically and endoscopically

The endpoint that matters most to patients is steroid-free clinical remission. Clinical relapse, defined by an increase in stool frequency and recurrence of rectal bleeding, and confirmed by endoscopy, is not the only approach to the evaluation of maintenance therapy, and several pivotal trials have addressed other endpoints. In particular, recent trial designs have tended to assess both induction and subsequent maintenance in the same study. Using this approach, clinical response to induction therapy has been defined as a primary endpoint, with the efficacy of maintenance therapy evaluated as a secondary endpoint,186 or as a co-primary endpoint,219 or as an endpoint for evaluation solely in those who have responded to and undergone re-randomisation at the end of induction therapy.189,193 Additionally, the definition of remission has varied, complicating efforts to make meaningful comparisons between different trials.220,221

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Alternative And Future Treatments

Several alternative therapies have emerged for the treatment of UC. Ova of the non-pathogenic helminth trichiuris suis taken orally has shown initial success in a double-blind placebo-controlled trial, inducing remission in 43% of patients taking ova compared with 16.7% in the placebo group. Transdermal administration of nicotine was proposed as being effective in active UC. A systematic review and analysis of 5 relevant studies demonstrated its effectiveness in achieving remission compared with placebo. However, direct comparative trials with 5-ASA are still missing. Omega-3 fatty acids, which are largely present in fish oil, have shown anti-inflammatory properties by reducing the production of leukotriene B4. However, in a meta-analysis of the 3 available studies on 138 UC patients in remission, no evidence was found to support the use of omega-3 fatty acids for maintenance of remission as similar relapse rates were found in the study group and the placebo group . Taken together, due to a lack of data on efficacy, safety and adverse events, no recommendation is given for the therapies mentioned above.

New Molecules Might Change The Approach To Asuc In The Future

In the last decade, many new options for treating IBD have become available. As some of these molecules can induce a rapid remission, they might be useful in the management of ASUC although data are still limited.64

Tofacitinib is a small molecule that inhibits the Janus kinases 1.2 and 3 which is a central molecule in pro-inflammatory cytokine production and response. In the OCTAVE trials tofacitinib was shown to induce remission more often than placebo in patients with moderate-to-severe ulcerative colitis that failed initial anti-TNF therapy.65 Post-hoc analysis of the trials moreover shows that induction of remission is particularly fast with these JAK inhibitors and occurs over a three-day period, making it a viable solution for treating ASUC.66 Data with tofacitinib in ASUC management are still limited, however. In a case series of 4 patients with ASUC, 3 out of 4 patients achieved clinical remission and colectomy was avoided in 50%.67 In another case series of again only 4 patients all patients achieved remission, and no one had to undergo colectomy.68 In a recent case series of 5 ASUC patients who had failed anti-TNF therapy, 3 improved under tofacitinib therapy while 2 eventually had to undergo a colectomy.69 Further prospective studies are needed.

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What Are The Causes Of Ulcerative Colitis

The exact cause of ulcerative colitis is not known. Though, according to modern medicine, one possible cause is an immune system malfunction. When the immune system tries to fight off an invading bacterium or virus, an abnormality in the immune system causes the immune system to attack the cells in the digestive tract too. Stress and diet aggravate this condition, further.

Active Ulcerative Colitis Of Any Extent Not Responding To 5

The first line treatment of mild to moderate left sided UC or pancolitis is combined topical and oral aminosalicylates . The combination of oral and rectal mesalamine seems to be superior to either therapy alone in patients with extensive colitis . 5-ASA is superior to placebo for induction of remission. In cases of failure to induce global or clinical improvement or remission, the pooled Peto odds ratio is 0.40 , 0.30 to 0.53) .

Figure 1

Patients with a first flare or patients with a maximum of one flare per year requiring systemic steroids should be started on 0.751 mg/kg of oral prednisone-equivalent for two to four weeks . After successful tapering of the steroids, maintenance therapy with topic and/or oral 5-ASA can be re-established . If remission cannot be maintained, the next course of oral steroids should be combined with azathioprine or mercaptopurine at 22.5 mg/kg or 11.5 mg/kg, respectively .

In a patient not responding to oral steroids, infection must be excluded. Stool cultures for bacteria and parasites and an assay for clostridium difficile must be obtained . Sigmoidoscopy should be performed to confirm the diagnosis and to exclude cytomegalovirus infection . If infection is excluded, treatment failure in this situation is called steroid-refractory. This topic will be discussed in the corresponding section below.

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Drugs Used In The Treatment Of Ibd

Therapy for IBD is a rapidly evolving field, with many new biological agents under investigation that are likely to change therapeutic strategies radically in the next decade. Details of the principal drugs can only be summarised in this document.

4.8.1 Aminosalicylates

, mesalamine in the USA.) Different formulations deliver millimolar concentrations to the gut lumen. Aminosalicylates are available as oral tablets, sachets or suspension, liquid or foam enemas, or suppositories. They act on epithelial cells by a variety of mechanisms to moderate the release of lipid mediators, cytokines, and reactive oxygen species. Oral forms include:

• pH dependent release/resin coated

• time controlled release

• delivery by carrier molecules, with release of 5-ASA after splitting by bacterial enzymes in the large intestine , olsalazine , balsalazide ).

Maintaining remission

Active disease

Adverse effects of 5-ASA

4.8.2 Corticosteroids

, or intravenous hydrocortisone, methylprednisolone.) Topical suppositories, foam or liquid enemas include hydrocortisone, prednisolone metasulphobenzoate, betamethasone, budesonide). Many strategies attempt to maximise topical effects while limiting systemic side effects of steroids. Budesonide is a poorly absorbed corticosteroid with limited bioavailability and extensive first pass metabolism that has therapeutic benefit with reduced systemic toxicity in ileocaecal CD, or UC.

Choice and mechanism

Efficacy for active UC

Efficacy for active CD

Efficacy

Fistulating And Perianal Disease72739596

Active perianal disease or fistulae are often associated with active CD elsewhere in the gastrointestinal tract. The initial aim should be to treat active disease and sepsis. For more complex, fistulating disease, the approach involves defining the anatomy, supporting nutrition, and potential surgery. For perianal disease, MRI and examination under anaesthetic are particularly helpful.

• Metronidazole 400 mg tds and/or ciprofloxacin 500 mg bd are appropriate first line treatments for simple perianal fistulae.

• Azathioprine 1.52.5 mg/kg/day or mercaptopurine 0.751.5 mg/kg/day are potentially effective for simple perianal fistulae or enterocutaneous fistulae where distal obstruction and abscess have been excluded .

• Infliximab should be reserved for patients whose perianal or enterocutaneous fistulae are refractory to other treatment and should be used as part of a strategy that includes immunomodulation and surgery .

• Surgery , including Seton drainage, fistulectomy, and the use of advancement flaps is appropriate for persistent or complex fistulae in combination with medical treatment .

• Elemental diets or parenteral nutrition have a role as adjunctive therapy, but not as sole therapy .

• There is insufficient evidence to recommend other agents outside clinical trials or specialist centres.

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Risk Factors For Relapse

Choice of maintenance treatment is determined by disease extent , disease course , failure and adverse events of previous maintenance treatment , severity of the most recent flare , treatment used for inducing remission during the most recent flare , safety of maintenance treatment , and cancer prevention

Patients with disease requiring steroids probably have a different outcome compared with the overall population of patients with UC. In a population-based study, the outcome of 183 patients with UC diagnosed between 1970 and 1993 was analysed 1 year after a first course of steroids.236 Among the 63/183 patients treated with corticosteroids, 49% had a prolonged response, 22% were steroid dependent, and 29% came to colectomy, but only 3/183 were treated with thiopurines.

Medical Management Of Crohns Disease

The severity of CD is more difficult to assess than UC. The general principles are to consider the site , pattern and activity of the disease before treatment decisions are made in conjunction with the patient.

An alternative explanation for symptoms other than active disease should be considered and disease activity confirmed before starting steroids. Individuals with CD have many investigations over their lifetime and imaging should not be repeated unless it will alter management or a surgical decision depends on the result.

Patients should be encouraged to participate actively in the decision to treat with high dose aminosalicylates, different corticosteroids, nutritional therapy, antibiotics, new biological agents, or surgery. Infliximab is considered in section 6.5.

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Medical Management Of Asuc

3.1. First Line Medical Therapy: Intravenous Corticosteroids

3.2. Second Line Medical Therapy or Rescue Therapies

3.2.1. Cyclosporine

3.2.2. Tacrolimus

3.2.3. Infliximab

3.2.4. Cyclosporine Versus Infliximab

3.3. Third Line Medical Therapy or Sequential Therapy

3.4. Other Medical Therapeutic Options

3.4.1. Tofacitinib

3.4.2. Vedolizumab

3.5. Emerging Therapies in Development

Chronic Active And Steroid Dependent Disease4559697191103

Long term treatment with steroids is undesirable. Patients who have a poor response to steroids can be divided into steroid refractory and steroid dependent. Steroid-refractory disease may be defined as active disease in spite of an adequate dose and duration of prednisolone and steroid dependence as a relapse when the steroid dose is reduced below 20 mg/day, or within 6 weeks of stopping steroids. Such patients should be considered for treatment with immunomodulators if surgery is not an immediate consideration.

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Box : Ulcerative Colitis: Induction Of Remission In Mild

Proctitis

• To induce remission in people with a mild-to-moderate first presentation or inflammatory exacerbation of proctitis, offer a topical aminosalicylate as first-line treatment
• If remission is not achieved within 4 weeks, consider adding an oral aminosalicylate
• If further treatment is needed, consider adding a time-limited course of a topical or an oral corticosteroid
• For people who decline a topical aminosalicylate:
• consider an oral aminosalicylate as first-line treatment, and explain that this is not as effective as a topical aminosalicylate
• if remission is not achieved within 4 weeks, consider adding a time-limited course of a topical or an oral corticosteroid

Proctosigmoiditis and left-sided ulcerative colitis

• To induce remission in people with a mild-to-moderate first presentation or inflammatory exacerbation of proctosigmoiditis or left-sided ulcerative colitis, offer a topical aminosalicylate as first-line treatment
• If remission is not achieved within 4 weeks, consider:
• adding a high-dose oral aminosalicylate to the topical aminosalicylate or
• switching to a high-dose oral aminosalicylate and a time-limited course of a topical corticosteroid

Extensive disease

Surveillance For Colonic Carcinoma24133136

The value of surveillance colonoscopy in UC remains debated. It is important to discuss with individual patients their risk of colorectal cancer, the implications should dysplasia be identified, the limitations of surveillance , and the small, but definable, risks of colonoscopy. A joint decision on the appropriateness of surveillance can then be made, taking the patients views into account.

• It is advisable that patients with UC should have a colonoscopy after 810 years to re-evaluate disease extent . Whether patients with previously extensive disease whose disease has regressed benefit from surveillance is unknown.

• For those with extensive colitis opting for surveillance, colonoscopies should be conducted every 3 years in the second decade, every 2 years in the third decade, and annually in the fourth decade of disease .

• Four random biopsies every 10 cm from the entire colon are best taken with additional samples of suspicious areas .

• Patients with primary sclerosing cholangitis appear to represent a subgroup at higher risk of cancer, and they should have more frequent colonoscopy .

• If dysplasia is detected, the biopsies should be reviewed by a second gastrointestinal pathologist and if confirmed, then colectomy is usually advisable .

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Adjuvant Therapeutic Considerations In Severe Uc

Antibiotic therapy is only recommended if infection is considered . Application of metronidazole or tobramycin has not shown consistent benefit in severe UC. Patients should be given enteral nutrition if tolerated and subileus/ileus are absent since bowel rest in acute colitis did not alter the outcome and enteral nutrition was shown to be associated with significantly fewer complications .

Box : Crohns Disease: Maintaining Remission After Surgery2

• To maintain remission in people with ileocolonic Crohns disease who have had complete macroscopic resection within the last 3 months, consider azathioprine in combination with up to 3 months postoperative metronidazole
• Consider azathioprine alone for those who cannot tolerate metronidazole
• Monitor the effects of azathioprine and metronidazole as advised in the BNF or BNFC. Monitor for neutropenia in people taking azathioprine even if they have normal TPMT activity
• Do not offer biologics to maintain remission after complete macroscopic resection of ileocolonic Crohns disease
• For people who had surgery and started taking biologics before this guideline was published , continue with their current treatment until both they and their NHS healthcare professional agree it is appropriate to change
• Do not offer budesonide to maintain remission in people with ileocolonic Crohns disease who have had complete macroscopic resection.

BNF=British National Formulary BNFC=British National Formulary for Children TPMT=thiopurine methyltransferase

© NICE 2019 Crohns disease: management. Available from www.nice.org.uk/ng129 All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this publication.

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Management Of Extraintestinal Manifestations146

Extraintestinal manifestations are found in both CD and UC. Those that are associated with active intestinal disease largely respond to therapy aimed at controlling disease activity, whereas those that occur whether disease is inactive or quiescent run a course independent of therapy for intestinal disease. Extraintestinal manifestations are more common in Crohns colitis and ileocolitis than in exclusively small bowel disease.