Editing Ulcerative colitis (section)

==Management==
{{Main|Management of ulcerative colitis}}
Standard treatment for ulcerative colitis depends on the extent of involvement and disease severity. The goal is to induce remission initially with medications, followed by the administration of maintenance medications to prevent a relapse. The concept of induction of remission and maintenance of remission is very important. The medications used to induce and maintain a remission somewhat overlap, but the treatments are different. Physicians first direct treatment to inducing remission, which involves relief of symptoms and mucosal healing of the colon's lining, and then longer-term treatment to maintain remission and prevent complications.<ref>{{cite journal | vauthors = Chen JH, Andrews JM, Kariyawasam V, Moran N, Gounder P, Collins G, Walsh AJ, Connor S, Lee TW, Koh CE, Chang J, Paramsothy S, Tattersall S, Lemberg DA, Radford-Smith G, Lawrance IC, McLachlan A, Moore GT, Corte C, Katelaris P, Leong RW | title = Review article: acute severe ulcerative colitis - evidence-based consensus statements | journal = Alimentary Pharmacology & Therapeutics | volume = 44 | issue = 2 | pages = 127–144 | date = July 2016 | pmid = 27226344 | doi = 10.1111/apt.13670 | doi-access = free }}</ref>

For acute stages of the disease, a [[Low-fiber/low-residue diet|low fiber diet]] may be recommended.<ref name=webmd>{{cite web|url=https://www.webmd.com/ibd-crohns-disease/low-residue-diet-foods#2|title=Should You Try a Low-Residue Diet?|website=WebMD|date=25 October 2016|access-date=29 April 2017}}</ref><ref name=manual_cnm>{{cite book|title=Manual of Clinical Nutrition Management|publisher=Compass Group|date=2013|url=https://bscn2k15.weebly.com/uploads/1/2/9/2/12924787/manual_of_clinical_nutrition2013.pdf}}</ref><ref>Roncoroni L, Gori R, Elli L, et al. Nutrition in Patients with Inflammatory Bowel Diseases: A Narrative Review. Nutrients. 2022;14(4):751. Published 2022 Feb 10. doi:10.3390/nu14040751</ref>

===Medication===
The first-line maintenance medication for ulcerative colitis in remission is [[mesalazine]] (also known as mesalamine or 5-ASA).<ref name="Ham Moss 2012 pp. 113–123">{{cite journal | last1=Ham | first1=Maggie | last2=Moss | first2=Alan C | title=Mesalamine in the treatment and maintenance of remission of ulcerative colitis | journal=Expert Review of Clinical Pharmacology | volume=5 | issue=2 | date=2012 | issn=1751-2433 | pmid=22390554 | pmc=3314328 | doi=10.1586/ecp.12.2 | pages=113–123}}</ref><ref name="Raine Bonovas Burisch Kucharzik 2022 pp. 2–17">{{cite journal | last1=Raine | first1=Tim | last2=Bonovas | first2=Stefanos | last3=Burisch | first3=Johan | last4=Kucharzik | first4=Torsten | last5=Adamina | first5=Michel | last6=Annese | first6=Vito | last7=Bachmann | first7=Oliver | last8=Bettenworth | first8=Dominik | last9=Chaparro | first9=Maria | last10=Czuber-Dochan | first10=Wladyslawa | last11=Eder | first11=Piotr | last12=Ellul | first12=Pierre | last13=Fidalgo | first13=Catarina | last14=Fiorino | first14=Gionata | last15=Gionchetti | first15=Paolo | last16=Gisbert | first16=Javier P | last17=Gordon | first17=Hannah | last18=Hedin | first18=Charlotte | last19=Holubar | first19=Stefan | last20=Iacucci | first20=Marietta | last21=Karmiris | first21=Konstantinos | last22=Katsanos | first22=Konstantinos | last23=Kopylov | first23=Uri | last24=Lakatos | first24=Peter L | last25=Lytras | first25=Theodore | last26=Lyutakov | first26=Ivan | last27=Noor | first27=Nurulamin | last28=Pellino | first28=Gianluca | last29=Piovani | first29=Daniele | last30=Savarino | first30=Edoardo | last31=Selvaggi | first31=Francesco | last32=Verstockt | first32=Bram | last33=Spinelli | first33=Antonino | last34=Panis | first34=Yves | last35=Doherty | first35=Glen | title=ECCO Guidelines on Therapeutics in Ulcerative Colitis: Medical Treatment | journal=Journal of Crohn's and Colitis | volume=16 | issue=1 | date=28 January 2022 | issn=1873-9946 | doi=10.1093/ecco-jcc/jjab178 | pages=2–17| pmid=34635919 }}</ref> For patients with active disease limited to the [[Descending colon|left colon]] (descending colon) or proctitis, mesalazine is also the first-line agent, and a combination of [[suppositories]] and oral mesalazine may be tried. Adding [[corticosteroid]]s such as [[prednisone]] is also common in active disease, especially if remission is not achieved through mesalazine monotherapy,<ref name="Ham Moss 2012 pp. 113–123"/><ref name="Raine Bonovas Burisch Kucharzik 2022 pp. 2–17"/> but they are not used in long-term treatment as their risks then outweigh their benefits. Immunosuppressive medications such as [[azathioprine]] and [[Biopharmaceutical|biological agent]]s such as [[infliximab]], [[adalimumab]], [[ustekinumab]], [[vedolizumab]], or [[risankizumab]] are given in severe disease or if a patient cannot achieve remission with mesalazine and corticosteroids.<ref name=AGAClinicalPractice2020>{{cite journal | vauthors = Feuerstein JD, Isaacs KL, Schneider Y, Siddique SM, Falck-Ytter Y, Singh S | title = AGA Clinical Practice Guidelines on the Management of Moderate to Severe Ulcerative Colitis | journal = Gastroenterology | volume = 158 | issue = 5 | pages = 1450–1461 | date = April 2020 | pmid = 31945371 | pmc = 7175923 | doi = 10.1053/j.gastro.2020.01.006 | doi-access = free }}</ref><ref name="Skyrizi FDA label">{{cite web | title=Skyrizi- risankizumab-rzaa kit | website=DailyMed | date=18 June 2024 | url=https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=7148c8eb-b39e-e20a-6494-a6df82392858 | access-date=2 November 2024}}</ref> As an alternative to mesalazine, one of its [[prodrug]]s such as [[sulfasalazine]] may be chosen for treatment of active disease or maintenance therapy,<ref name="Sandborn 2002 pp. 2939–2941">{{cite journal | last=Sandborn | first=W | title=Rational selection of oral 5-aminosalicylate formulations and prodrugs for the treatment of ulcerative colitis | journal=The American Journal of Gastroenterology | volume=97 | issue=12 | date=2002 | doi=10.1016/S0002-9270(02)05509-0 | pages=2939–2941| pmid=12492172 }}</ref> but the prodrugs have greater potential for serious side effects and have not been demonstrated to be superior to mesalazine in large trials.<ref name="Ko Singh Feuerstein Falck-Ytter 2019 pp. 748–764">{{cite journal | last1=Ko | first1=Cynthia W. | last2=Singh | first2=Siddharth | last3=Feuerstein | first3=Joseph D. | last4=Falck-Ytter | first4=Corinna | last5=Falck-Ytter | first5=Yngve | last6=Cross | first6=Raymond K. | last7=Crockett | first7=Seth | last8=Falck-Ytter | first8=Yngve | last9=Feuerstein | first9=Joseph | last10=Flamm | first10=Steven | last11=Inadomi | first11=John | last12=Ko | first12=Cynthia | last13=Muniraj | first13=Thiruvengadam | last14=O’Shea | first14=Robert | last15=Pandolfino | first15=John | last16=Patel | first16=Amit | last17=Sharaf | first17=Ravi | last18=Siddique | first18=Shazia | last19=Su | first19=Grace | last20=Wang | first20=Kenneth | last21=Weizman | first21=Adam | title=AGA Clinical Practice Guidelines on the Management of Mild-to-Moderate Ulcerative Colitis | journal=Gastroenterology | volume=156 | issue=3 | date=2019 | pmid=30576644 | pmc=6858922 | doi=10.1053/j.gastro.2018.12.009 | pages=748–764}}</ref>

A formulation of [[budesonide]] was approved by the U.S. [[Food and Drug Administration]] (FDA) for treatment of active ulcerative colitis in January 2013.<ref>{{cite news |title=FDA approves Uceris as ulcerative colitis treatment |url=https://www.healio.com/news/gastroenterology/20130115/santarus_10_3928_1081_597x_20130101_15_997579 |work=Healio Gastroenterology |date=15 January 2013}}</ref><ref>{{cite web |title=UCERIS (budesonide) extended release tablets label |url=https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/203634s000lbl.pdf |publisher=FDA}}</ref> In 2018, [[tofacitinib]] was approved for treatment of moderately to severely active ulcerative colitis in the United States, the first oral medication indicated for long term use in this condition.<ref>{{cite press release|url=https://www.fda.gov/news-events/press-announcements/fda-approves-new-treatment-moderately-severely-active-ulcerative-colitis |title=FDA approves new treatment for moderately to severely active ulcerative colitis|website=U.S. [[Food and Drug Administration]] (FDA) |date=30 May 2018 |access-date=31 May 2018}}</ref> The evidence on [[methotrexate]] does not show a benefit in producing remission in people with ulcerative colitis.<ref>{{cite journal | vauthors = Chande N, Wang Y, MacDonald JK, McDonald JW | title = Methotrexate for induction of remission in ulcerative colitis | journal = The Cochrane Database of Systematic Reviews | volume = 8 | issue = 8 | pages = CD006618 | date = August 2014 | pmid = 25162749 | pmc = 6486224 | doi = 10.1002/14651858.CD006618.pub3 }}</ref> [[Cyclosporine]] is effective for severe UC<ref name=AGAClinicalPractice2020 /> and [[tacrolimus]] has also shown benefits.<ref>{{cite journal | vauthors = Krishnamoorthy R, Abrams KR, Guthrie N, Samuel S, Thomas T |s2cid=74798482 |title=PWE-237 Ciclosporin in acute severe ulcerative colitis: a meta-analysis |journal=Gut |date=28 May 2012 |volume=61 |issue=Suppl 2 |pages=A394.2–A394 |doi=10.1136/gutjnl-2012-302514d.237|doi-access=free }}</ref><ref>{{cite journal | vauthors = Ogata H, Kato J, Hirai F, Hida N, Matsui T, Matsumoto T, Koyanagi K, Hibi T | title = Double-blind, placebo-controlled trial of oral tacrolimus (FK506) in the management of hospitalized patients with steroid-refractory ulcerative colitis | journal = Inflammatory Bowel Diseases | volume = 18 | issue = 5 | pages = 803–808 | date = May 2012 | pmid = 21887732 | doi = 10.1002/ibd.21853 | s2cid = 1294555 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Lichtiger S, Present DH, Kornbluth A, Gelernt I, Bauer J, Galler G, Michelassi F, Hanauer S | title = Cyclosporine in severe ulcerative colitis refractory to steroid therapy | journal = The New England Journal of Medicine | volume = 330 | issue = 26 | pages = 1841–1845 | date = June 1994 | pmid = 8196726 | doi = 10.1056/NEJM199406303302601 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Weisshof R, Ollech JE, El Jurdi K, Yvellez OV, Cohen RD, Sakuraba A, Dalal S, Pekow J, Rubin DT | title = Ciclosporin Therapy After Infliximab Failure in Hospitalized Patients With Acute Severe Colitis is Effective and Safe | journal = Journal of Crohn's & Colitis | volume = 13 | issue = 9 | pages = 1105–1110 | date = September 2019 | pmid = 30726894 | pmc = 7327272 | doi = 10.1093/ecco-jcc/jjz032 }}</ref> [[Etrasimod]] was approved for medical use in the United States in October 2023.<ref>{{cite press release | title=U.S. FDA Approves Pfizer's Velsipity for Adults with Moderately to Severely Active Ulcerative Colitis (UC) | publisher=Pfizer | via=Business Wire | date=13 October 2023 | url=https://www.businesswire.com/news/home/20231012073213/en/ | access-date=13 October 2023}}</ref>

====Aminosalicylates====
Sulfasalazine has been a major agent in the therapy of mild to moderate ulcerative colitis for over 50 years. In 1977, it was shown that 5-aminosalicylic acid (5-ASA, [[mesalazine]]/mesalamine) was the therapeutically active component in sulfasalazine.<ref>{{cite journal | vauthors = Azad Khan AK, Piris J, Truelove SC | title = An experiment to determine the active therapeutic moiety of sulphasalazine | journal = Lancet | volume = 2 | issue = 8044 | pages = 892–895 | date = October 1977 | pmid = 72239 | doi = 10.1016/s0140-6736(77)90831-5 | s2cid = 44785199 }}</ref>  Many 5-ASA drugs have been developed with the aim of delivering the active compound to the large intestine to maintain therapeutic efficacy but with reduction of the side effects associated with the sulfapyridine moiety in sulfasalazine.  Oral 5-ASA drugs are particularly effective in inducing and in maintaining remission in mild to moderate ulcerative colitis.<ref>{{cite journal | vauthors = Murray A, Nguyen TM, Parker CE, Feagan BG, MacDonald JK | title = Oral 5-aminosalicylic acid for induction of remission in ulcerative colitis | journal = The Cochrane Database of Systematic Reviews | volume = 2020 | issue = 8 | pages = CD000543 | date = August 2020 | pmid = 32786164 | pmc = 8189994 | doi = 10.1002/14651858.CD000543.pub5 }}</ref><ref>{{cite journal | vauthors = Murray A, Nguyen TM, Parker CE, Feagan BG, MacDonald JK | title = Oral 5-aminosalicylic acid for maintenance of remission in ulcerative colitis | journal = The Cochrane Database of Systematic Reviews | volume = 2020 | issue = 8 | pages = CD000544 | date = August 2020 | pmid = 32856298 | pmc = 8094989 | doi = 10.1002/14651858.CD000544.pub5 }}</ref>  Rectal suppository, foam or liquid enema formulations of 5-ASA are used for colitis affecting the rectum, sigmoid or descending colon, and have been shown to be effective especially when combined with oral treatment.<ref>{{cite journal | vauthors = Marshall JK, Thabane M, Steinhart AH, Newman JR, Anand A, Irvine EJ | title = Rectal 5-aminosalicylic acid for maintenance of remission in ulcerative colitis | journal = The Cochrane Database of Systematic Reviews | volume = 11 | pages = CD004118 | date = November 2012 | pmid = 23152224 | doi = 10.1002/14651858.CD004118.pub2 | pmc = 11972843 }}</ref>

====Biologics====
Biologic treatments such as the [[TNF inhibitor]]s [[infliximab]], [[adalimumab]], and [[golimumab]] are commonly used to treat people with UC who are no longer responding to corticosteroids. [[Tofacitinib]] and [[vedolizumab]] can also produce good clinical remission and response rates in UC.<ref name=Hir2015/> Biologics may be used early in treatment (step down approach), or after other treatments have failed to induce remission (step up approach); the strategy should be individualized.<ref>{{cite journal | vauthors = Salahudeen MS | title = A review of current evidence allied to step-up and top-down medication therapy in inflammatory bowel disease | journal = Drugs of Today | volume = 55 | issue = 6 | pages = 385–405 | date = June 2019 | pmid = 31250843 | doi = 10.1358/dot.2019.55.6.2969816 | s2cid = 195763151 }}</ref>

Unlike aminosalicylates, biologics can cause serious side effects such as an increased risk of developing extra-intestinal cancers,<ref name=AxelradLichtiger2016>{{cite journal | vauthors = Axelrad JE, Lichtiger S, Yajnik V | title = Inflammatory bowel disease and cancer: The role of inflammation, immunosuppression, and cancer treatment | journal = World Journal of Gastroenterology | volume = 22 | issue = 20 | pages = 4794–4801 | date = May 2016 | pmid = 27239106 | pmc = 4873872 | doi = 10.3748/wjg.v22.i20.4794 | type = Review | doi-access = free }}</ref> [[heart failure]]; and weakening of the immune system, resulting in a [[Immunodeficiency|decreased ability of the immune system to clear infections]] and reactivation of latent infections such as [[tuberculosis]]. For this reason, people on these treatments are closely monitored and are often tested for hepatitis and tuberculosis annually.<ref>{{cite journal | vauthors = Stevens JP, Ballengee CR, Chandradevan R, Thompson AB, Schoen BT, Kugathasan S, Sauer CG | title = Performance of Interferon-Gamma Release Assays for Tuberculosis Screening in Pediatric Inflammatory Bowel Disease | journal = Journal of Pediatric Gastroenterology and Nutrition | volume = 69 | issue = 4 | pages = e111–e116 | date = October 2019 | pmid = 31261245 | doi = 10.1097/MPG.0000000000002428 | s2cid = 195771593 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Lee CK, Wong SH, Lui G, Tang W, Tam LS, Ip M, Hung E, Chen M, Wu JC, Ng SC | title = A Prospective Study to Monitor for Tuberculosis During Anti-tumour Necrosis Factor Therapy in Patients With Inflammatory Bowel Disease and Immune-mediated Inflammatory Diseases | journal = Journal of Crohn's & Colitis | volume = 12 | issue = 8 | pages = 954–962 | date = July 2018 | pmid = 29757355 | doi = 10.1093/ecco-jcc/jjy057 | s2cid = 21673794 | doi-access = free }}</ref>

Etrasimod, a once-daily oral sphingosine 1-phosphate (S1P) receptor modulator that selectively activates S1P receptor subtypes 1, 4, and 5 with no detectable activity on S1P 2 or 3, is in development for treatment of immune-mediated diseases, including ulcerative colitis, and was shown in 2 randomized trials to be effective and well tolerated as induction and maintenance therapy in patients with moderately to severely active ulcerative colitis.<ref>{{cite journal |last1=Sandborn |first1=William J. |last2=Vermeire |first2=Séverine |last3=Peyrin-Biroulet |first3=Laurent |last4=Dubinsky |first4=Marla C. |last5=Panes |first5=Julian |last6=Yarur |first6=Andres |last7=Ritter |first7=Timothy |last8=Baert |first8=Filip |last9=Schreiber |first9=Stefan |last10=Sloan |first10=Sheldon |last11=Cataldi |first11=Fabio |last12=Shan |first12=Kevin |last13=Rabbat |first13=Christopher J. |last14=Chiorean |first14=Michael |last15=Wolf |first15=Douglas C. |date=8 April 2023 |title=Etrasimod as induction and maintenance therapy for ulcerative colitis (ELEVATE): two randomised, double-blind, placebo-controlled, phase 3 studies |journal=The Lancet |language=English |volume=401 |issue=10383 |pages=1159–1171 |doi=10.1016/S0140-6736(23)00061-2 |issn=0140-6736 |pmid=36871574|s2cid=257286271 |doi-access=free }}</ref>

====Nicotine====
Unlike [[Crohn's disease]], ulcerative colitis has a lesser chance of affecting smokers than non-smokers.<ref>{{cite journal | vauthors = Calkins BM | title = A meta-analysis of the role of smoking in inflammatory bowel disease | journal = Digestive Diseases and Sciences | volume = 34 | issue = 12 | pages = 1841–1854 | date = December 1989 | pmid = 2598752 | doi = 10.1007/BF01536701 | s2cid = 5775169 }}</ref><ref>{{cite journal | vauthors = Lakatos PL, Szamosi T, Lakatos L | title = Smoking in inflammatory bowel diseases: good, bad or ugly? | journal = World Journal of Gastroenterology | volume = 13 | issue = 46 | pages = 6134–6139 | date = December 2007 | pmid = 18069751 | pmc = 4171221 | doi = 10.3748/wjg.13.6134 | doi-access = free }}</ref> In select individuals with a history of previous tobacco use, resuming low dose smoking may improve signs and symptoms of active ulcerative colitis,<ref>{{cite journal | vauthors = Calabrese E, Yanai H, Shuster D, Rubin DT, Hanauer SB | title = Low-dose smoking resumption in ex-smokers with refractory ulcerative colitis | journal = Journal of Crohn's & Colitis | volume = 6 | issue = 7 | pages = 756–762 | date = August 2012 | pmid = 22398093 | doi = 10.1016/j.crohns.2011.12.010 | doi-access = free }}</ref> but it is not recommended due to the overwhelmingly negative [[health effects of tobacco]].<ref name=Cosnes2004>{{cite journal | vauthors = Cosnes J | title = Tobacco and IBD: relevance in the understanding of disease mechanisms and clinical practice | journal = Best Practice & Research. Clinical Gastroenterology | volume = 18 | issue = 3 | pages = 481–496 | date = June 2004 | pmid = 15157822 | doi = 10.1016/j.bpg.2003.12.003 }}</ref> Studies using a [[transdermal nicotine]] patch have shown clinical and histological improvement.<ref>{{cite journal | vauthors = Guslandi M | title = Nicotine treatment for ulcerative colitis | journal = British Journal of Clinical Pharmacology | volume = 48 | issue = 4 | pages = 481–484 | date = October 1999 | pmid = 10583016 | pmc = 2014383 | doi = 10.1046/j.1365-2125.1999.00039.x | df = dmy-all }}</ref> In one double-blind, placebo-controlled study conducted in the [[United Kingdom]], 48.6% of people with UC who used the nicotine patch, in conjunction with their standard treatment, showed complete resolution of symptoms. Another randomized, double-blind, placebo-controlled, single-center clinical trial conducted in the [[United States]] showed that 39% of people who used the patch showed significant improvement, versus 9% of those given a placebo.<ref>{{cite journal | vauthors = Sandborn WJ, Tremaine WJ, Offord KP, Lawson GM, Petersen BT, Batts KP, Croghan IT, Dale LC, Schroeder DR, Hurt RD | title = Transdermal nicotine for mildly to moderately active ulcerative colitis. A randomized, double-blind, placebo-controlled trial | journal = Annals of Internal Medicine | volume = 126 | issue = 5 | pages = 364–371 | date = March 1997 | pmid = 9054280 | doi = 10.7326/0003-4819-126-5-199703010-00004 | s2cid = 25745900 }}</ref> However, nicotine therapy is generally not recommended due to side effects and inconsistent results.<ref>{{cite journal | vauthors = Bonapace CR, Mays DA | title = The effect of mesalamine and nicotine in the treatment of inflammatory bowel disease | journal = The Annals of Pharmacotherapy | volume = 31 | issue = 7–8 | pages = 907–913 | date = 1997 | pmid = 9220055 | doi = 10.1177/106002809703100719 | s2cid = 24122049 }}</ref><ref>{{cite journal | vauthors = Kennedy LD | title = Nicotine therapy for ulcerative colitis | journal = The Annals of Pharmacotherapy | volume = 30 | issue = 9 | pages = 1022–1023 | date = September 1996 | pmid = 8876866 }}</ref><ref>{{cite journal | vauthors = Rubin DT, Hanauer SB | title = Smoking and inflammatory bowel disease | journal = European Journal of Gastroenterology & Hepatology | volume = 12 | issue = 8 | pages = 855–862 | date = August 2000 | pmid = 10958212 | doi = 10.1097/00042737-200012080-00004 }}</ref>

====Iron supplementation====
The gradual loss of blood from the gastrointestinal tract, as well as chronic inflammation, often leads to anemia, and professional guidelines suggest routinely monitoring for anemia with blood tests repeated every three months in active disease and annually in quiescent disease.<ref name="ReferenceA">{{cite journal | vauthors = Goddard AF, James MW, McIntyre AS, Scott BB | title = Guidelines for the management of iron deficiency anaemia | journal = Gut | volume = 60 | issue = 10 | pages = 1309–1316 | date = October 2011 | pmid = 21561874 | doi = 10.1136/gut.2010.228874 | collaboration = British Society of Gastroenterology | doi-access = free }}</ref> Adequate disease control usually improves anemia of chronic disease, but iron deficiency anemia should be treated with iron supplements. The form in which treatment is administered depends both on the severity of the anemia and on the guidelines that are followed. Some advise that [[parenteral iron]] be used first because people respond to it more quickly, it is associated with fewer gastrointestinal side effects, and it is not associated with compliance issues.<ref name="pmid17985376">{{cite journal | vauthors = Gasche C, Berstad A, Befrits R, Beglinger C, Dignass A, Erichsen K, Gomollon F, Hjortswang H, Koutroubakis I, Kulnigg S, Oldenburg B, Rampton D, Schroeder O, Stein J, Travis S, Van Assche G | title = Guidelines on the diagnosis and management of iron deficiency and anemia in inflammatory bowel diseases | journal = Inflammatory Bowel Diseases | volume = 13 | issue = 12 | pages = 1545–1553 | date = December 2007 | pmid = 17985376 | doi = 10.1002/ibd.20285 | doi-access = free }}</ref> Others require oral iron to be used first, as people eventually respond and many will tolerate the side effects.<ref name="ReferenceA"/><ref name=Mowat2011>{{cite journal | vauthors = Mowat C, Cole A, Windsor A, Ahmad T, Arnott I, Driscoll R, Mitton S, Orchard T, Rutter M, Younge L, Lees C, Ho GT, Satsangi J, Bloom S | title = Guidelines for the management of inflammatory bowel disease in adults | journal = Gut | volume = 60 | issue = 5 | pages = 571–607 | date = May 2011 | pmid = 21464096 | doi = 10.1136/gut.2010.224154 | s2cid = 8269837 }}</ref>

====Anticholinergics====
[[Anticholinergic]] drugs, more specifically [[muscarinic antagonist]]s, are sometimes used to treat abdominal cramps in connection with ulcerative colitis through their calming effect on colonic [[peristalsis]] (reducing both amplitude and frequency) and [[Muscle tone|intestinal tone]].<ref name="Can Med Assoc J p. ">{{cite journal | title=Drugs for Ulcerative Colitis | journal=Canadian Medical Association Journal | date=1964 | publisher=Can Med Assoc J | volume=91 | issue=21 | issn=0008-4409 | pmid=14229762 | author1=O'SULLIVAN PM | pages=1123–1124 | pmc=1928363 }}</ref><ref name="Camilleri Szarka 2008 pp. 1108–1156">{{cite book | last1=Camilleri | first1=Michael | last2=Szarka | first2=Lawrence | title=Textbook of Gastroenterology | chapter=Dysmotility of the Small Intestine and Colon | publisher=Wiley | date=14 November 2008 | isbn=978-1-4051-6911-0 | doi=10.1002/9781444303254.ch47 | pages=1108–1156| s2cid=83791469 }}</ref> Some medical authorities suggest over-the-counter anticholinergic drugs as potential helpful treatments for abdominal cramping in mild ulcerative colitis.<ref name="Amanda Fernandez, OMS IV Ronald Januchowski, DO, FACOFP 2020 pp. 10–16">{{cite journal | author=Amanda Fernandez, OMS IV | author2=Ronald Januchowski, DO, FACOFP | title=Osteopathic Primary Care Treatment Options for Ulcerative Colitis | journal=Osteopathic Family Physician | volume=12 | issue=3 | date=30 April 2020 | issn=1877-573X | doi=10.33181/12031 | pages=10–16| s2cid=219029672 }}</ref> However, their use is contraindicated especially in moderate to severe disease states because of the potential for anticholinergic treatment to induce [[toxic megacolon]] in patients with colonic inflammation.<ref name="Sedano Quera Simian Yarur 2019 pp. 943–955">{{cite journal | last1=Sedano | first1=Rocío | last2=Quera | first2=Rodrigo | last3=Simian | first3=Daniela | last4=Yarur | first4=Andres J. | title=An approach to acute severe ulcerative colitis | journal=Expert Review of Gastroenterology & Hepatology | publisher=Informa UK Limited | volume=13 | issue=10 | date=3 October 2019 | issn=1747-4124 | doi=10.1080/17474124.2019.1681974 | pages=943–955| pmid=31648574 | s2cid=204891274 }}</ref> Toxic megacolon is a state in which the colon is abnormally distended, and may in severe or untreated cases lead to colonic [[perforation]], sepsis, and death.<ref name="Desai Elnaggar Hanfy Doshi 2020 pp. 203–210">{{cite journal | last1=Desai | first1=Jiten | last2=Elnaggar | first2=Mohamed | last3=Hanfy | first3=Ahmed A. | last4=Doshi | first4=Rajkumar | title=Toxic Megacolon: Background, Pathophysiology, Management Challenges and Solutions | journal=Clinical and Experimental Gastroenterology | volume=13 | date=19 May 2020 | pmid=32547151 | pmc=7245441 | doi=10.2147/CEG.S200760 | pages=203–210 | doi-access=free }}</ref>

=== Immunosuppressant therapies, infection risks and vaccinations ===

Many patients affected by ulcerative colitis need immunosuppressant therapies, which may be associated with a higher risk of contracting opportunistic infectious diseases.<ref>Toruner, M.; Loftus, E.V.; Harmsen, W.S.; Zinsmeister, A.R.; Orenstein, R.; Sandborn, W.J.; Colombel, J.; Egan, L.J. Risk factors for opportunistic infections in patients with inflammatory bowel disease. Gastroenterology 2008, 134, 929–936</ref>
Many of these potentially harmful diseases, such as [[Hepatitis B]], [[Influenza]], [[chickenpox]], [[Varicella zoster virus|herpes zoster virus]], [[pneumococcal pneumonia]], or [[Human papillomavirus infection|human papilloma virus]], can be prevented by vaccines. Each drug used in the treatment of IBD should be classified according to the degree of immunosuppression induced in the patient. Several guidelines suggest investigating patients' vaccination status before starting any treatment and performing vaccinations against vaccine preventable diseases when required.<ref>Farraye, F.A.; Melmed, G.Y.; Lichtenstein, G.R.; Kane, S.V. ACG Clinical Guideline: Preventive Care in Inflammatory Bowel Disease. Am. J. Gastroenterol. 2017, 112, 241–258.</ref><ref>Kucharzik, T.; Ellul, P.; Greuter, T.; Rahier, J.F.; Verstockt, B.; Abreu, C.; Albuquerque, A.; Allocca, M.; Esteve, M.; Farraye, F.A.; et al. ECCO Guidelines on the Prevention, Diagnosis, and Management of Infections in Inflammatory Bowel Disease. J. Crohn’s Colitis 2021, 15, 879–913.</ref> 
Compared to the rest of the population, patients affected by IBD are known to be at higher risk of contracting some vaccine-preventable diseases.<ref>Ananthakrishnan, A.N.; McGinley, E.L. Infection-related hospitalizations are associated with increased mortality in patients with inflammatory bowel diseases. J. Crohn’s Colitis 2013, 7, 107–112.</ref> Patients treated with [[Janus kinase inhibitor]] showed higher risk of  [[Shingles]].<ref>Winthrop, K.L.; Melmed, G.Y.; Vermeire, S.; Long, M.D.; Chan, G.; Pedersen, R.D.; Lawendy, N.; Thorpe, A.J.; Nduaka, C.I.; Su, C. Herpes Zoster Infection in Patients with Ulcerative Colitis Receiving Tofacitinib. Inflamm. Bowel Dis. 2018, 24, 2258–2265</ref>  Nevertheless, despite the increased risk of infections, vaccination rates in IBD patients are known to be suboptimal and may also be lower than vaccination rates in the general population.<ref>Malhi, G.; Rumman, A.; Thanabalan, R.; Croitoru, K.; Silverberg, M.S.; Steinhart, A.H.; Nguyen, G.C. Vaccination in inflammatory bowel disease patients: Attitudes, knowledge, and uptake. J. Crohn’s Colitis 2015, 9, 439–444.</ref><ref>Costantino, A.; Michelon, M.; Noviello, D.; Macaluso, F.S.; Leone, S.; Bonaccorso, N.; Costantino, C.; Vecchi, M.; Caprioli, F., on behalf of AMICI Scientific Board. Attitudes towards Vaccinations in a National Italian Cohort of Patients with Inflammatory Bowel Disease. Vaccines 2023, 11, 1591.</ref>

===Surgery===
{{Treatment in CD vs. UC}}
Unlike in Crohn's disease, the gastrointestinal aspects of ulcerative colitis can generally be cured by [[colectomy|surgical removal of the large intestine]], though extraintestinal symptoms may persist. This procedure is necessary in the event of: [[exsanguination|exsanguinating]] [[internal bleeding|hemorrhage]], frank perforation, or documented or strongly suspected [[carcinoma]]. Surgery is also indicated for people with severe colitis or toxic megacolon. People with symptoms that are disabling and do not respond to drugs may wish to consider whether surgery would improve the quality of life.<ref name=":1" />

The removal of the entire large intestine, known as a [[proctocolectomy]], results in a permanent ileostomy – where a [[Stoma (medicine)|stoma]] is created by pulling the terminal ileum through the abdomen. Intestinal contents are emptied into a removable [[Ostomy pouching system|ostomy bag]] which is secured around the stoma using adhesive.<ref>{{cite web |title=Living with a stoma |url=https://www.ibdrelief.com/living-with-ibd/living-with-a-stoma |publisher=IBD Relief}}</ref>

Another surgical option for ulcerative colitis that is affecting most of the large bowel is called the [[ileo-anal pouch|ileal pouch-anal anastomosis (IPAA)]]. This is a two- or three-step procedure. In a three-step procedure, the first surgery is a [[Subtotal colectomy|sub-total colectomy]], in which the large bowel is removed, but the rectum remains in situ, and a temporary ileostomy is made. The second step is a [[Proctocolectomy|proctectomy]] and formation of the ileal pouch (commonly known as a "j-pouch"). This involves removing the large majority of the remaining rectal stump and creating a new "rectum" by fashioning the end of the small intestine into a pouch and attaching it to the anus. After this procedure, a new type of ileostomy is created (known as a loop ileostomy) to allow the anastomoses to heal. The final surgery is a take-down procedure where the ileostomy is reversed and there is no longer the need for an ostomy bag. When done in two steps, a proctocolectomy – removing both the colon and rectum – is performed alongside the pouch formation and loop ileostomy. The final step is the same take-down surgery as in the three-step procedure. Time taken between each step can vary, but typically a six- to twelve-month interval is recommended between the first two steps, and a minimum of two to three months is required between the formation of the pouch and the ileostomy take-down.<ref name=":1" />

While the ileal pouch procedure removes the need for an ostomy bag, it does not restore normal bowel function. In the months following the final operation, patients typically experience 8–15 bowel movements a day. Over time this number decreases, with many patients reporting 4–6 bowel movements after one year post-op. While many patients have success with this procedure, there are a number of known complications. [[Pouchitis]], inflammation of the ileal pouch resulting in symptoms similar to ulcerative colitis, is relatively common. Pouchitis can be acute, remitting, or chronic however treatment using antibiotics, steroids, or biologics can be highly effective. Other complications include fistulas, abscesses, and pouch failure. Depending on the severity of the condition, pouch revision surgery may need to be performed. In some cased the pouch may need to be de-functioned or removed and an ileostomy recreated.<ref>{{cite web |title=Colectomy Not a Final Cure for Ulcerative Colitis, Data Show |url=https://www.mdedge.com/internalmedicine/article/11622/gastroenterology/colectomy-not-final-cure-ulcerative-colitis-data |website=www.mdedge.com |access-date=15 December 2019 |language=en}}</ref><ref>{{cite journal | vauthors = Pappou EP, Kiran RP | title = The Failed J Pouch | journal = Clinics in Colon and Rectal Surgery | volume = 29 | issue = 2 | pages = 123–129 | date = June 2016 | pmid = 27247537 | pmc = 4882179 | doi = 10.1055/s-0036-1580724 }}</ref>

The risk of cancer arising from an ileal pouch anal anastomosis is low.<ref name=Clarke /> However, annual surveillance with [[pouchoscopy]] may be considered in individuals with risk factors for dysplasia, such as a history of dysplasia or colorectal cancer, a history of PSC, refractory pouchitis, and severely inflamed atrophic pouch mucosa.<ref name=Clarke>{{cite journal | vauthors = Clarke WT, Feuerstein JD | title = Colorectal cancer surveillance in inflammatory bowel disease: Practice guidelines and recent developments | journal = World Journal of Gastroenterology | volume = 25 | issue = 30 | pages = 4148–4157 | date = August 2019 | pmid = 31435169 | pmc = 6700690 | doi = 10.3748/wjg.v25.i30.4148 | s2cid = 201114672 | doi-access = free }}</ref>

===Bacterial recolonization===
In a number of randomized clinical trials, [[probiotics]] have demonstrated the potential to be helpful in the treatment of ulcerative colitis. Specific types of probiotics such as [[Escherichia coli Nissle 1917|''Escherichia coli'' Nissle]] have been shown to induce remission in some people for up to a year.<ref name=Fedorak>{{cite journal | vauthors = Fedorak RN | title = Probiotics in the management of ulcerative colitis | journal = Gastroenterology & Hepatology | volume = 6 | issue = 11 | pages = 688–690 | date = November 2010 | pmid = 21437015 | pmc = 3033537 }}</ref>

A [[Cochrane (organisation)|Cochrane]] review of [[controlled trials]] using various probiotics found low-certainty evidence that probiotic supplements may increase the probability of clinical remission.<ref name=":5">{{cite journal |last1=Kaur |first1=Lakhbir |last2=Gordon |first2=Morris |last3=Baines |first3=Patricia Anne |last4=Iheozor-Ejiofor |first4=Zipporah |last5=Sinopoulou |first5=Vasiliki |last6=Akobeng |first6=Anthony K |date=4 March 2020 |editor-last=Cochrane IBD Group |title=Probiotics for induction of remission in ulcerative colitis |journal=Cochrane Database of Systematic Reviews |volume=3 |issue=3 |pages=CD005573 |language=en |doi=10.1002/14651858.CD005573.pub3 |pmc=7059959 |pmid=32128795}}</ref> People receiving probiotics were 73% more likely to experience disease remission and over 2x as likely to report improvement in symptoms compared to those receiving a placebo, with no clear difference in minor or serious adverse effects.<ref name=":5" /> Although there was no clear evidence of greater remission when probiotic supplements were compared with [[Mesalazine|5‐aminosalicylic acid]] treatment as a [[monotherapy]], the likelihood of remission was 22% higher if probiotics were used in combination with 5-aminosalicylic acid therapy.<ref name=":5" />

It is unclear whether probiotics help to prevent future relapse in people with stable disease activity, either as a monotherapy or [[combination therapy]].<ref>{{cite journal |last1=Iheozor-Ejiofor |first1=Zipporah |last2=Kaur |first2=Lakhbir |last3=Gordon |first3=Morris |last4=Baines |first4=Patricia Anne |last5=Sinopoulou |first5=Vasiliki |last6=Akobeng |first6=Anthony K |date=4 March 2020 |editor-last=Cochrane IBD Group |title=Probiotics for maintenance of remission in ulcerative colitis |journal=Cochrane Database of Systematic Reviews |volume=3 |issue=3 |pages=CD007443 |language=en |doi=10.1002/14651858.CD007443.pub3 |pmc=7059960 |pmid=32128794}}</ref>

[[Fecal microbiota transplant]] involves the infusion of human probiotics through fecal enemas. Ulcerative colitis typically requires a more prolonged bacteriotherapy treatment than ''Clostridioides difficile'' infection does to be successful, possibly due to the time needed to heal the ulcerated epithelium. The response of ulcerative colitis is potentially very favorable with one study reporting 67.7% of people experiencing complete remission.<ref name="pmid24257037">{{cite journal | vauthors = Borody TJ, Brandt LJ, Paramsothy S | title = Therapeutic faecal microbiota transplantation: current status and future developments | journal = Current Opinion in Gastroenterology | volume = 30 | issue = 1 | pages = 97–105 | date = January 2014 | pmid = 24257037 | pmc = 3868025 | doi = 10.1097/MOG.0000000000000027 }}</ref> Other studies found a benefit from using fecal microbiota transplantation.<ref>{{cite journal | vauthors = Narula N, Kassam Z, Yuan Y, Colombel JF, Ponsioen C, Reinisch W, Moayyedi P | title = Systematic Review and Meta-analysis: Fecal Microbiota Transplantation for Treatment of Active Ulcerative Colitis | journal = Inflammatory Bowel Diseases | volume = 23 | issue = 10 | pages = 1702–1709 | date = October 2017 | pmid = 28906291 | doi = 10.1097/MIB.0000000000001228 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Shi Y, Dong Y, Huang W, Zhu D, Mao H, Su P | title = Fecal Microbiota Transplantation for Ulcerative Colitis: A Systematic Review and Meta-Analysis | journal = PLOS ONE | volume = 11 | issue = 6 | pages = e0157259 | date = 2016 | pmid = 27295210 | pmc = 4905678 | doi = 10.1371/journal.pone.0157259 | doi-access = free | bibcode = 2016PLoSO..1157259S }}</ref><ref>{{cite journal | vauthors = Costello SP, Hughes PA, Waters O, Bryant RV, Vincent AD, Blatchford P, Katsikeros R, Makanyanga J, Campaniello MA, Mavrangelos C, Rosewarne CP, Bickley C, Peters C, Schoeman MN, Conlon MA, Roberts-Thomson IC, Andrews JM | title = Effect of Fecal Microbiota Transplantation on 8-Week Remission in Patients With Ulcerative Colitis: A Randomized Clinical Trial | journal = JAMA | volume = 321 | issue = 2 | pages = 156–164 | date = January 2019 | pmid = 30644982 | pmc = 6439766 | doi = 10.1001/jama.2018.20046 }}</ref>

===Alternative medicine===
A variety of alternative medicine therapies have been used for ulcerative colitis, with inconsistent results. [[Turmeric|Curcumin (turmeric)]] therapy, in conjunction with taking the medications [[Mesalazine|mesalamine]] or [[sulfasalazine]], may be effective and safe for maintaining remission in people with quiescent ulcerative colitis.<ref>{{cite journal | vauthors = Hanai H, Iida T, Takeuchi K, Watanabe F, Maruyama Y, Andoh A, Tsujikawa T, Fujiyama Y, Mitsuyama K, Sata M, Yamada M, Iwaoka Y, Kanke K, Hiraishi H, Hirayama K, Arai H, Yoshii S, Uchijima M, Nagata T, Koide Y | title = Curcumin maintenance therapy for ulcerative colitis: randomized, multicenter, double-blind, placebo-controlled trial | journal = Clinical Gastroenterology and Hepatology | volume = 4 | issue = 12 | pages = 1502–1506 | date = December 2006 | pmid = 17101300 | doi = 10.1016/j.cgh.2006.08.008 | url = http://www.cghjournal.org/article/S1542356506008007/pdf }}</ref><ref name=Kumar /> The effect of [[Turmeric|curcumin]] therapy alone on quiescent ulcerative colitis is unknown.<ref name=Kumar>{{cite journal | vauthors = Kumar S, Ahuja V, Sankar MJ, Kumar A, Moss AC | title = Curcumin for maintenance of remission in ulcerative colitis | journal = The Cochrane Database of Systematic Reviews | volume = 10 | pages = CD008424 | date = October 2012 | pmid = 23076948 | pmc = 4001731 | doi = 10.1002/14651858.CD008424.pub2 }}</ref>

Treatments using [[Cannabis (drug)|cannabis]] or cannabis oil are uncertain. So far, studies have not determined its effectiveness and safety.<ref>{{cite journal | vauthors = Kafil TS, Nguyen TM, MacDonald JK, Chande N | title = Cannabis for the treatment of ulcerative colitis | journal = The Cochrane Database of Systematic Reviews | volume = 11 | pages = CD012954 | date = November 2018 | issue = 11 | pmid = 30406638 | pmc = 6516819 | doi = 10.1002/14651858.CD012954.pub2 }}</ref>

=== Abdominal pain management ===
Many interventions have been considered to manage abdominal pain in people with ulcerative colitis, including [[FODMAP]]s diet, [[Relaxation technique|relaxation]] training, [[yoga]], [[kefir]] diet and stellate [[Ganglionic blocker|ganglion block]] treatment. It is unclear whether any of these are safe or effective at improving pain or reducing [[anxiety]] and [[Depression (mood)|depression]].<ref>{{cite journal | vauthors = Sinopoulou V, Gordon M, Dovey TM, Akobeng AK | title = Interventions for the management of abdominal pain in ulcerative colitis | journal = The Cochrane Database of Systematic Reviews | volume = 2021 | issue = 7 | pages = CD013589 | date = July 2021 | pmid = 34291816 | pmc = 8407332 | doi = 10.1002/14651858.CD013589.pub2 | collaboration = Cochrane Gut Group }}</ref>

==== Nutrition ====

Diet can play a role in symptoms of patients with ulcerative colitis.<ref>De Souza, H.; Fiocchi, C.; Iliopoulos, D. The IBD interactome: An integrated view of aetiology, pathogenesis and therapy. Nat. Rev. Gastroenterol. Hepatol. 2017, 14, 739–749</ref>

The most avoided foods by patients are spicy foods, dairy products, alcohol, fruits and vegetables and carbonated beverages; these foods are mainly avoided during remission and to prevent relapse. In some cases, especially in the flares period, the dietary restrictions of these patients can be very severe and can lead to a compromised nutritional state. Some patients tend to eliminate gluten spontaneously, despite not having a definite diagnosis of [[Coeliac disease]], because they believe that gluten can exacerbate gastrointestinal symptoms.<ref>{{cite journal |last1=Roncoroni |first1=Leda |last2=Gori |first2=Rachele |last3=Elli |first3=Luca |last4=Tontini |first4=Gian Eugenio |last5=Doneda |first5=Luisa |last6=Norsa |first6=Lorenzo |last7=Cuomo |first7=Marialaura |last8=Lombardo |first8=Vincenza |last9=Scricciolo |first9=Alice |last10=Caprioli |first10=Flavio |last11=Costantino |first11=Andrea |last12=Scaramella |first12=Lucia |last13=Vecchi |first13=Maurizio |title=Nutrition in Patients with Inflammatory Bowel Diseases: A Narrative Review |journal=Nutrients |date=10 February 2022 |volume=14 |issue=4 |pages=751 |doi=10.3390/nu14040751 |pmid=35215401 |pmc=8879392 |issn=2072-6643 |doi-access=free }}{{Creative Commons text attribution notice|cc=by4|from this source=yes}}</ref>

===Mental health===
Many studies found that patients with IBD reported a higher frequency of depressive and anxiety disorders than the general population, and most studies confirm that women with IBD are more likely than men to develop affective disorders and show that up to 65% of them may have [[depression disorder]] and [[anxiety disorder]].<ref name="doi.org">Fracas E, Costantino A, Vecchi M, Buoli M. Depressive and Anxiety Disorders in Patients with Inflammatory Bowel Diseases: Are There Any Gender Differences? International Journal of Environmental Research and Public Health. 2023; 20(13):6255. https://doi.org/10.3390/ijerph20136255</ref><ref>Barberio B, Zamani M, Black CJ, Savarino EV, Ford AC. Prevalence of symptoms of anxiety and depression in patients with inflammatory bowel disease: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol. 2021 May;6(5):359-370. doi: 10.1016/S2468-1253(21)00014-5</ref>

A meta analysis of interventions to improve mood (including talking therapy, [[antidepressant]]s, and exercise) in people with inflammatory bowel disease found that they reduced inflammatory markers such as [[C-reactive protein]] and [[faecal calprotectin]]. Psychological therapies reduced inflammation more than antidepressants or exercise.<ref>{{Cite journal |last1=Seaton |first1=Natasha |last2=Hudson |first2=Joanna |last3=Harding |first3=Sophie |last4=Norton |first4=Sam |last5=Mondelli |first5=Valeria |last6=Jones |first6=Annie S.K. |last7=Moss-Morris |first7=Rona |date=2 February 2024 |title=Do interventions for mood improve inflammatory biomarkers in inflammatory bowel disease?: a systematic review and meta-analysis |url=https://doi.org/10.1016/j.ebiom.2023.104910 |journal=eBioMedicine |volume=100 |pages=104910 |doi=10.1016/j.ebiom.2023.104910 |issn=2352-3964 |pmc=10878994 |pmid=38272759}}</ref><ref>{{Cite journal |date=17 July 2024 |title=Improving mood reduces inflammation in inflammatory bowel disease |url=https://evidence.nihr.ac.uk/alert/improving-mood-reduces-inflammation-in-inflammatory-bowel-disease/ |journal=NIHR Evidence|doi=10.3310/nihrevidence_63192 }}</ref>