Therapy for ulcerative colitis - Current treatment approaches

Treatment of Ulcerative Colitis – Current Therapeutic Approaches Based on the S3 Guidelines

The treatment of ulcerative colitis (UC) pursues several goals. On one hand, the inflammation in the intestine should be reduced; on the other, symptoms should be alleviated. Additionally, the therapy aims for long-term remission — ideally without the use of corticosteroids. But what treatment options exist, and how are they individually tailored based on disease progression and severity? In this article, you’ll learn everything about modern treatment strategies for UC, based on the current S3 guideline for the diagnosis and treatment of ulcerative colitis.

What Is the Goal of Ulcerative Colitis Therapy?

Currently, there is no cure for ulcerative colitis. The primary goals of therapy are:

To achieve rapid clinical remission (freedom from symptoms).
To promote endoscopic remission (no visible inflammation in the colon).
To minimize or completely avoid the use of corticosteroids.

Which Factors Influence the Choice of Therapy?

Selecting the right therapy is a shared decision between doctor and patient. Past experiences with side effects and the severity of the disease also play a key role in choosing the appropriate treatment.

Treatment of Mild to Moderate Ulcerative Colitis

Depending on the disease pattern, UC is categorized as:

E1: Proctitis (only the rectum is affected)
E2: Left-sided colitis (left side of the abdomen is affected)
E3: Extensive colitis (entire colon is affected)

1. Flare Therapy for Proctitis

The first-line treatment for mild to moderate proctitis is mesalazine in the form of suppositories. Alternatively, mesalazine can also be administered via foam or enemas.
If rectal therapy alone does not provide sufficient relief, it can be combined with topical corticosteroids (e.g., budesonide foam) or oral mesalazine.

Topical corticosteroids are corticosteroids (also known as glucocorticoids or cortisone) applied locally. Depending on the treatment area, they are used as sprays, drops, enemas, foams, or creams. Their local application helps reduce systemic side effects.

2. Flare Therapy for Left-Sided Colitis

For mild to moderate left-sided colitis, rectal mesalazine is also recommended — typically as enemas or foam. Experts also recommend starting oral mesalazine right away to enhance effectiveness.
If symptoms persist, the addition of topical corticosteroids like budesonide foam is advised.

3. Flare Therapy for Extensive Colitis

The principles of treating extensive UC are similar to those for left-sided colitis. Oral mesalazine combined with rectal mesalazine (foam or enemas) is the standard approach.
If symptoms do not improve, increasing the oral mesalazine dose is recommended.

Therapy Options for Mild to Moderate UC – An Overview

Mesalazine (oral & rectal)
Topical corticosteroids (e.g., budesonide)
Combination therapy if necessary

New Treatment Approaches & Future Developments

In addition to established medications, several innovative therapies are under investigation:

Biologics & JAK inhibitors: Innovative drugs for more severe cases
Mesenchymal stem cell therapy: A promising area of research
Microbiome therapies: Modifying gut flora to reduce inflammation

Key Updates in the 2024 S3 Guideline

The current S3 guideline for ulcerative colitis (June 2024) includes several important changes:

Newly added treatment options:
- Upadacitinib and Mirikizumab have been included for the first time.
- The guideline now recommends alternatives for patients unresponsive to aminosalicylates.
- Dosing and use of TNF antibodies in complex cases have been specified.
Updated approach to complicated cases:
- The guideline now explicitly recommends early escalation to biologics or JAK inhibitors in steroid-dependent UC.
New focus on personalized treatment:
- The guideline emphasizes the importance of patient-specific factors such as disease history, comorbidities, and response to previous therapies.

Conclusion: Which Therapy Is Right for You?

The best therapy depends on your disease course, symptom severity, and individual circumstances.

Mesalazine remains the standard treatment for mild to moderate cases.
Corticosteroids should only be used short-term and in severe flares.
New medications and biologics are reserved for more severe or complicated cases.

➡️ Speak with your doctor about which option is best for you!

Want to Learn More?
💡 Check out our article on cutting-edge IBD treatments: Mesenchymal Stem Cells – New Hope for IBD Patients

Frequently Asked Questions About Ulcerative Colitis Therapy

Can ulcerative colitis be cured?
Many patients achieve long-term remission with the right therapy, but a cure is not currently possible.

What if my medications don’t work?
Talk to your doctor about adjusting your treatment or trying newer medications.

Are biologics better than mesalazine?
Not necessarily – biologics are intended for more severe cases, while mesalazine is often sufficient for mild disease.

Is there a specific diet that helps?
A tailored diet can support treatment but does not replace medication. Learn more in our article on nutrition and IBD.

Sources

Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS). (2024). S3-Leitlinie zur Diagnostik und Therapie der Colitis ulcerosa (Version 2024-06). AWMF-Register-Nr. 021-009. Z Gastroenterol 2024; 62: 769–858 DOI 10.1055/a-2271-0994