Ulcerative colitis, steady medication is the most important thingProfessor Seong-Joon Ko, Department of Gastroenterology, Seoul National University Hospital

 

 

 

Ulcerative colitis is a chronic inflammation of the large intestine of unknown origin. It is characterized by inflammation localized in the mucous membrane or submucosal layer of the large intestine, with repeated improvements and exacerbations. The main symptoms are diarrhea, bloody stools, and abdominal pain, and when it becomes chronic, the patient may feel discomfort, reduce the quality of life, and in severe cases, may have to have a colon removed.

 

The exact cause of ulcerative colitis is not known, but it is believed to be caused by a combination of immune system abnormalities caused by genetic abnormalities, intestinal microbiota, or environmental factors.

 

Although the name of the disease is 'ulcerative colitis', the disease itself is not characterized by an ulcer, but rather 'erosion', which is a thin inflammation that forms in the intestinal mucosal layer. The erosion goes through a process of improvement and deterioration repeatedly, and if it becomes severe, ulcers may form.

*Erosion: Defects in the surface layer of the skin or mucous membranes

Who usually gets ulcerative colitis?

 

Ulcerative colitis mainly occurs in people in their 20s~30s, but the prevalence rate is higher in those in their 40s~50s. This is because the patients who developed the disease in the 80s~90s have not yet been cured. In addition, recent epidemiological analyses have a higher prevalence in males.

 

The prevalence of ulcerative colitis has been steadily increasing by more than 30% over a five-year period. Globally, it is estimated that by 2030, 1% of the population will suffer from inflammatory bowel diseases, including ulcerative colitis and Crohn's disease, and the trend is increasing in Korea.

 

It is difficult to change the genetic factors that are the cause of the gradual increase in ulcerative colitis in a short period of time. It can be assumed that ulcerative colitis is on the rise due to the following factors:

 

 

These environmental changes seem to have caused changes in the microbial ecosystem in the human gut, leading to a gradual increase in the prevalence of ulcerative colitis.

 

What are the symptoms of ulcerative colitis?

 

The main symptoms of ulcerative colitis are diarrhea, bloody stools, and mucous stools. These symptoms vary from patient to patient, but they go through a process of getting better and worse. Ulcerative colitis is indistinguishable from normal diarrhea by its diarrhea pattern, but acute diarrhea improves without treatment within 2 weeks, but ulcerative colitis has diarrhea symptoms that last for more than 4 weeks. If this is the case, you should go to the hospital for an examination.

 

Ulcerative colitis can be diagnosed with a colonoscopy or biopsy. With colonoscopy, there is an overall red intestinal color, redness. Edema, mucus, glaze, erosion, and ulcers can be identified, and biopsy can be diagnosed by observing structural alterations and chronic inflammatory cell infiltration.

 

Why do I need maintenance treatment for ulcerative colitis?

 

There is no concept of cure for ulcerative colitis. It is a disease with a high recurrence rate of about 30% within 1 year. Ongoing treatment is required to reduce the risk of recurrence.

 

In more than half of asymptomatic patients, intestinal inflammation remains, and it gradually worsens through a process of improvement and exacerbation, eventually increasing the likelihood of complications such as intestinal narrowing and colon cancer, so maintenance treatment is essential. You should not stop prescribed medications without consulting your doctor.

 

In the past, the goal of treatment for ulcerative colitis was clinical remission* by improving symptoms such as diarrhea and bloody stools, but recently, the goal of treatment has been added to this goal: healing the intestinal mucosa. The criterion for healing of the intestinal mucosa is the absence of all mucosal inflammation during colonoscopy.

*Remission: Almost no symptoms

 

There are two types of treatments: 'step up', that is, gradually changing from a weak drug to a stronger drug, and a 'top down' method, which is changing from a strong drug to a weaker drug after improvement. You may wonder if a step up is the right treatment, but a top down approach may be a good option for those who are doing well. Depending on the characteristics of the patient, the appropriate treatment is applied.

 

5-ASA, which is taken in the first phase of the drug administration, is administered by more than 90% of patients with inflammatory bowel disease and has been used for the treatment of ulcerative colitis for a long time due to its anti-inflammatory effect by inhibiting substances called COX* and PPARγ*. For moderately severe patients, steroid treatment will be performed first, and then maintenance treatment with 5-ASA when remission is achieved.

*COX: Enzymes that make cyclooxygenase, prostaglandins

*PPARγ: Pipa gamma, expressed in adipose tissue and involved in secreting various cytokines

 

The problem lies in the fact that due to the nature of ulcerative colitis, which has repeated remission and exacerbation, the patient's adherence to medication decreases during the period of remission. Decreased adherence means that you don't take your medications on time as prescribed by your doctor. In order to prevent recurrence, even if the symptoms improve, it is necessary to take medicine as prescribed by the doctor. In fact, statistics show that when patients are adhered to well, the recurrence rate decreases to a comparable level.

 

Therefore, it is important to consider the mechanism of 5-ASA and find a way to increase medication adherence. Additional things you can consider to improve adherence include:

 

 

In addition, allowing patients to take the medication in a variety of ways that they can take it in a way that is convenient for them will have the effect of increasing adherence. For example, 5-ASA may be prescribed as an anal implant rather than orally if you have difficulty swallowing the medication, as it is effective when given in the form of a suppository if the rectum is inflamed only.

 

Continuation of maintenance treatment can improve the quality of life by maintaining remission, reduce the number of hospital visits/hospitalizations, reduce direct and indirect medical costs, and reduce the risk of bowel resection surgery and colorectal cancer.

 

Since ulcerative colitis cannot be cured, it is important to treat it with appropriate drugs during the active period to create remission, and once it is achieved, how to maintain it without recurrence. One of the factors that increases the success rate of maintenance therapy is patient adherence. It is of utmost importance to take the medicine consistently. You should also have a colonoscopy periodically. In remission, it is recommended to undergo examination every 1~2 years, and in the active phase, 6 months after drug administration.