Medications for People with Ulcerative Colitis

Ulcerative colitis (UC) is a type of inflammatory bowel disease (IBD) that mainly affects the large intestine, in particular the colon. UC may be caused by an abnormal response from your body’s immune system.

While there’s no known cure for UC, several types of medication can be used to help manage your symptoms.

Symptoms of UC can include:

• abdominal pain, discomfort, or cramps
• persistent diarrhea
• blood in the stool

Symptoms may be constant, or they may get worse during flare-ups.

Various medications can be used to:

• decrease swelling and irritation caused by inflammation
• reduce the number of flare-ups you have
• allow your colon to heal

Five main classes of drugs are used to treat UC. Learn more about them, their benefits, and their possible side effects.

Aminosalicylates are thought to help reduce UC symptoms by decreasing inflammation in the colon. They’re also known as 5-ASA drugs.

These drugs are recommended for people with mild to moderate UC. They can help prevent flare-ups or reduce the number of flare-ups you have.

Examples include:

Mesalamine

Mesalamine may be taken orally as:

• a delayed-release tablet
• an extended-release capsule
• a delayed-release capsule

Mesalamine is also available as a rectal suppository or rectal enema.

Some forms of mesalamine are available as generic drugs. It also has several brand-name versions, such as:

• Apriso
• Asacol HD
• Canasa
• Delzicol
• Lialda
• Pentasa
• Rowasa
• sfRowasa (sulfite-free Rowasa)

Side effects and interactions

The more common side effects of mesalamine can include:

• diarrhea
• headache
• nausea
• abdominal pain, cramps, and discomfort
• burping
• rash

Rare but serious side effects of mesalamine can include:

• chest pain
• shortness of breath
• irregular heart rhythm
• liver failure

Examples of drugs that mesalamine can interact with include:

• azathioprine (Azasan, Imuran), an immunosuppressant that’s sometimes used to treat UC
• mercaptopurine (Purixan), a chemotherapy drug that’s sometimes used to treat UC
• nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen (Advil, Motrin)

Olsalazine

Olsalazine comes as a capsule you take by mouth. It’s available as the brand-name drug Dipentum.

Olsalazine is not available as a generic drug.

Side effects and interactions

The more common side effects of olsalazine can include:

• diarrhea or loose stools
• abdominal pain
• rash or itching

Serious side effects of olsalazine can include:

• blood disorders such as anemia
• liver failure
• heart problems, such as inflammation of your heart and changes in your heart rhythm

Examples of drugs and biologic agents that olsalazine can interact with include:

• heparin, a blood thinner
• low-molecular-weight heparins such as enoxaparin (Lovenox) or dalteparin (Fragmin)
• thioguanine, a chemotherapy drug
• mercaptopurine
• the varicella zoster vaccine

Balsalazide

Balsalazide comes as a capsule you take by mouth.

The capsule is available as a generic drug and as the brand-name drug Colazal.

Side effects and interactions

The more common side effects of balsalazide can include:

• headache
• abdominal pain
• diarrhea
• nausea
• vomiting
• respiratory infection
• joint pain

Serious side effects of balsalazide can include blood disorders such as anemia and liver failure.

Balsalazide may interact with NSAIDs or azathioprine. People who are allergic to aspirin or other salicylates should not take balsalazide.

Sulfasalazine

Sulfasalazine is taken by mouth as:

• an immediate-release tablet
• a delayed-release tablet

It’s available as a generic drug and as the brand-name drug Azulfidine.

Side effects and interactions

The more common side effects of sulfasalazine can include:

• loss of appetite
• headache
• nausea
• vomiting
• upset stomach
• decreased sperm count in men

Other rare but serious side effects of sulfasalazine include:

• blood disorders such as anemia
• severe allergic reactions such as the skin condition Stevens-Johnson syndrome
• liver failure
• kidney problems

Sulfasalazine may interact with other drugs, such as folic acid or the heart disease medication digoxin (Lanoxin).

Important considerations

The American Gastroenterological Association (AGA) strongly recommends that adults with extensive mild to moderate disease choose standard-dose oral mesalamine or diazo-bonded 5-ASA drugs over low dose mesalamine, sulfasalazine, or no treatment at all.

Standard-dose mesalamine is 2 to 3 grams per day.

Olsalazine and balsalazide are examples of diazo-bonded 5-ASA drugs. After you take these drugs, bacteria in your colon convert them into mesalamine.

It’s fine for some people to stick with sulfasalazine, such as those whose condition is already in remission via treatment with the drug or who may not be able to afford other drugs. However, sulfasalazine does come with a greater risk of side effects.

If you don’t respond to standard-dose mesalamine or diazo-bonded 5-ASA drugs, then the AGA suggests a combination of rectal mesalamine and high dose oral mesalamine (more than 3 grams/day).

Corticosteroids decrease your body’s overall immune system response. This helps to reduce inflammation in your body. These types of drugs are used to moderate to severe active UC.

Corticosteroids include:

Budesonide

The Food and Drug Administration (FDA) has approved two forms of budesonide for UC:

• an extended-release tablet
• a rectal foam

Both are available as the brand-name drug Uceris. The tablet is also available as a generic drug.

Side effects and interactions

The more common side effects of budesonide can include:

• headache
• nausea
• decreased levels of the hormone cortisol
• pain in your upper abdomen
• tiredness
• bloating
• acne
• urinary tract infection (UTI)
• joint pain
• constipation

Serious side effects of budesonide can include:

• anaphylaxis
• infection in people who are taking immunosuppressants
• high blood pressure
• low potassium, which is marked by symptoms such as leg cramps, increased thirst, and increased urination

Budesonide can interact with other drugs such as:

• protease inhibitors, such as ritonavir (Norvir) and saquinavir (Invirase), which are used to treat HIV
• antifungal drugs, such as itraconazole (Sporanox, Onmel) and ketoconazole (Extina)
• erythromycin (Eryc, Ery-Tab), an antibiotic

People taking high doses of budesonide or other corticosteroids should also avoid live vaccines. They include the:

• nasal flu vaccine
• varicella vaccine
• measles, mumps, and rubella (MMR) vaccine

Prednisone, prednisolone, and methylprednisolone

Prednisone is taken by mouth and is available as:

• an immediate-release tablet
• a delayed-release tablet
• a liquid solution

It’s available as a generic drug and as the brand-name drugs Prednisone Intensol (liquid solution) and Rayos (delayed-release tablet).

The forms of prednisolone that are FDA approved for UC are:

• immediate-release tablet
• dissolving tablet
• liquid solution
• syrup

You can take any of these forms by mouth. Prednisolone is available as a generic drug and as the brand-name drugs Millipred (liquid solution) and Prelone (syrup).

Methylprednisolone comes in two forms:

• oral tablet
• injectable medication

It’s available as a generic drug and as the brand-name drugs Medrol (oral tablet) and Depo-Medrol (injectable medication).

Side effects, complications, and interactions

When given in high doses, the side effects of these drugs are similar. The more common side effects can include:

• increased blood sugar levels
• restlessness or anxiety
• increased blood pressure
• swelling due to fluid retention in your legs or ankles
• increased appetite
• weight gain
• headache
• thinning skin
• changes to your menstrual cycle

Serious side effects and complications are similar to the ones associated with budesonide. They can include:

• anaphylaxis
• osteoporosis and increased risk of bone fracture
• heart problems such as heart attack, chest pain, and changes in your heart rhythm
• seizures
• low potassium

Examples of drugs that prednisone, prednisolone, and methylprednisolone can interact with include:

• antiseizure drugs such as phenytoin (Dilantin)
• blood thinners such as warfarin (Coumadin, Jantoven) and heparin
• the antibiotics cyclosporine (Neoral, Sandimmune), ketoconazole, and rifampin
• aspirin

People taking high doses of these drugs should also avoid live vaccines, such as the:

• nasal flu vaccine
• varicella vaccine
• MMR vaccine

Immunomodulators are drugs that decrease the body’s response to its own immune system. The result is lowered inflammation throughout your body.

Immunomodulators may reduce the number of UC flare-ups you have and help you stay symptom-free longer.

They’re generally prescribed to people whose symptoms haven’t been managed with 5-ASA drugs and corticosteroids. However, these drugs may take several months to start working.

The FDA has not approved immunomodulators for the treatment of UC.

However, they’re well supported in medical literature as useful options, and your doctor may still prescribe them. This is known as off-label drug use.

Methotrexate

Methotrexate is available as an oral tablet. It can also be given as an intravenous (IV), intramuscular, or subcutaneous injection.

The tablet is available as a generic drug and as the brand-name drug Trexall.

The IV and intramuscular injections are available as generic drugs. The subcutaneous injection is available as the brand-name drugs Otrexup and Rasuvo.

Azathioprine

For UC treatment, azathioprine comes as a tablet you take by mouth. It’s available as a generic drug and as the brand-name drugs Azasan and Imuran.

Mercaptopurine

Mercaptopurine is available as a tablet or a liquid suspension, both taken by mouth.

The tablet is only available as a generic drug, and the suspension is only available as the brand-name drug Purixan.

Tacrolimus

Tacrolimus is available in the following forms:

• capsule
• extended-release capsule
• extended-release tablet
• liquid suspension
• injectable medication

Brand-name versions of the drug include Astagraf XL (extended-release capsule), Envarsus XR (extended-release tablet), and Prograf (various forms).

Tacrolimus is also available as a generic medication.

Side effects and interactions

The more common side effects of these immunomodulators can include:

• headache
• nausea
• vomiting
• diarrhea
• mouth sores
• tiredness
• low blood cell levels

Examples of drugs that immunomodulators can interact with include:

• the gout medications allopurinol (Lopurin, Zyloprim) and probenecid (Probalan)
• 5-ASA drugs, such as sulfasalazine, mesalamine, and olsalazine
• angiotensin-converting enzyme (ACE) inhibitors, such as lisinopril (Prinivil, Zestril) and enalapril (Epaned, Vasotec)
• warfarin
• ribavirin (Rebetol, Virazole), a hepatitis C medication
• NSAIDs, such as naproxen and ibuprofen
• phenytoin
• sulfonamides, a group of antibiotics

Important considerations

A 2018 study has suggested that methotrexate may not be noticeably more effective than placebo at maintaining remission for UC.

People with UC also have a higher risk for developing stomach and intestinal problems when taking low dose methotrexate, according to a 2016 case report.

Janus kinase (JAK) inhibitors decrease the body’s immune response and block signals that lead to inflammation.

These medications are used for moderate to severe UC. They work more quickly than other treatments.

Tofacitinib

In 2018, the FDA approved the use of tofacitinib for UC treatment.

It was previously FDA approved to treat rheumatoid arthritis, but it had been used off-label to treat UC.

Tofacitinib comes as:

• an immediate-release tablet
• an extended-release tablet
• a liquid solution

It’s only available under the brand names Xeljanz and Xeljanz XR. Xeljanz is the first medication of its kind that’s taken orally — rather than by injection — for long-term treatment of UC.

Side effects, complications, and interactions

Side effects and complications may include:

• diarrhea
• headache
• infections, including pneumonia and appendicitis
• skin cancer
• pulmonary embolism
• anemia

Tofacitinib may cause a negative reaction when used with other medications, such as:

• ketoconazole
• rifampin
• immunosuppressants, such as azathioprine

Important considerations

Tofacitinib should only be used in the lowest amount needed to be effective.

Pfizer sponsored a post-marketing safety study that was conducted between 2014 and 2020. It involved a little over 4,300 participants ages 50 years and older and diagnosed with rheumatoid arthritis. Results showed an increased risk of blood clots (thrombosis) in those who had at least cardiovascular risk factor.

Health Canada followed up with a safety review of Tofacitinib in 2019.

Upadacitinib

In March 2022, the FDA approved the use of another JAK inhibitor called upadacitinib for UC treatment.

Like tofacitinib, upadacitinib is an oral medication that blocks a specific enzyme involved in inflammation. This medication is available as an extended-release tablet.

It’s available under the brand name Rinvoq.

Side effects, complications, and interactions

Side effects and complications of upadacitinib may include:

• runny or stuffy nose
• nausea
• acne

More severe complications may include:

• allergic reaction that can include hives, swelling, and difficulty swallowing or breathing
• stomach pain or gastrointestinal perforations
• heart attack or stroke
• lymphoma
• skin cancer
• serious infection
• thrombosis
• low white blood cell count
• anemia

Upadacitinib may decrease the body’s ability to fight fungal, viral, or bacterial infections. This can increase the risk that you will develop a serious infection while taking this medication.

This medication may interact with immunosuppressant drugs. These are drugs that decrease the function of the immune system.

Upadacitinib may cause a negative reaction when used with other medications and supplements, such as:

• certain antifungal medications, including itraconazole (Onmel, Sporanox), ketoconazole, and voriconazole (Vfend)
• certain medications for HIV, including indinavir (Crixivan), nelfinavir (Viracept), ritonavir (Norvir, in Kaletra), and saquinavir (Invirase)
• NSAIDs such as aspirin and ibuprofen (Advil, Motrin)
• nefazodone
• phenytoin (Phenytek, Dilantin Infatabs, Dilantin Kapseal)
• antibiotics rifabutin (Mycobutin) and rifampin (Rifadin)
• St. John’s wort, an herbal supplement

Important considerations

Upadacitinib should not be used if you’re pregnant or may become pregnant. You should not breastfeed while taking this medication.

You may not be able to receive vaccinations while taking this medication.

Biologics are genetically designed drugs developed in a lab from a living organism. These drugs prevent certain proteins in your body from causing inflammation. Biologics are generally used to treat moderate to severe UC.

They’re also used when symptoms are not able to be managed with treatments such as 5-ASA drugs, corticosteroids, or immunomodulators.

Biologics are only available as brand-name drugs.

However, biosimilar drugs do exist. Biosimilars are not exact copies of biologics, but they’re very similar in effectiveness, strength, and side effects. They’re also cheaper.

Due to patent laws, most biosimilars aren’t yet available for purchase in the United States. Only the Remicade biosimilars Renflexis, Avsola, and Inflectra are currently available.

Tumor necrosis factor (TNF) inhibitors that are FDA approved to treat UC in adults include:

• adalimumab (Humira), given by subcutaneous injection
• adalimumab-adaz (Hyrimoz), given by subcutaneous injection
• adalimumab-adbm (Cyltezo), given by subcutaneous injection
• adalimumab-afzb (Abrilada), given by subcutaneous injection
• adalimumab-atto (Amjevita), given by subcutaneous injection
• adalimumab-bwwd (Hadlima), given by subcutaneous injection
• adalimumab-fkjp (Hulio), given by subcutaneous injection
• golimumab (Simponi), given by subcutaneous injection
• infliximab (Remicade), given by IV infusion
• infliximab-abda (Renflexis), given by IV infusion
• infliximab-axxq (Avsola), given by IV infusion
• infliximab-dyyb (Inflectra), given by IV infusion

In February 2021, the FDA also approved Humira for the treatment of moderate to severe UC in children ages 5 years and older.

Other types of biologics include:

• Ustekinumab (Stelara). Induction dosing is given by IV infusion, while maintenance is given by injection.
• Vedolizumab (Entyvio). The drug is given (administered) by IV infusion.

You may need to take biologics for up to 8 weeks before you see any improvement.

Side effects and interactions

The more common side effects of biologics can include:

• headache
• fever
• chills
• nausea
• hives or rash
• increased infections

Biologic drugs may interact with other drugs and biologic agents, including:

• natalizumab (Tysabri), which can be used to treat Crohn’s disease or multiple sclerosis
• tocilizumab (Actemra), anakinra (Kineret), abatacept (Orencia), which are primarily used to treat arthritis
• warfarin
• cyclosporine
• theophylline (Theo-24, Theochron), an asthma medication
• live vaccines such as the varicella zoster vaccine

Important considerations

If you have moderate to severe UC and you’ve never tried a biologic before, then the AGA suggests that you choose infliximab or vedolizumab over adalimumab. They’re more effective.

However, it’s fine to choose adalimumab instead if you prefer to administer the medication yourself as opposed to having a doctor administer it for you.

Your doctor may prescribe other medications to help treat certain symptoms. For example, antibiotics may be used to treat UC-related infections.

Loperamide (Imodium), which is available over the counter, may help with diarrhea. You may also use anti-gas remedies to help relieve bloating.

Make sure to check with your doctor before taking any new medications, even if they’re over the counter.

NSAIDs, such as ibuprofen, aspirin, and naproxen, typically help reduce fever or inflammation in the body.

If you have UC, though, these drugs may make your symptoms worse. Be sure to talk with your doctor before taking an NSAID.

It’s also important to tell your doctor about any medications you’re taking to ensure that they do not interact with any of your UC treatments.

Many drugs can help reduce your UC symptoms.

Your doctor will suggest medications based on factors such as your overall health and the severity of your condition. You may need to try a few medications before you find a treatment plan that works for you.

If taking one medication does not reduce your symptoms enough, your doctor may add a second medication that makes the first one more effective.

It may take some time, but your doctor will work with you to find the right medications to help relieve your UC symptoms.

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