Medical Therapy for Ulcerative Colitis
Initial treatment with one drug at a single dose and one delivery route is the traditional and easiest way for both the clinician and patient to judge the efficacy and tolerability of a treatment. Most evidence-based data is based on this approach. Patient compliance with using a single drug is likely to be better than with multiple drugs or multiple delivery routes and the cost will probably be less.
If the initial treatment
is not effective or tolerable, then the dose can be adjusted,
with or without starting other drugs. The main drawback tosequential therapy is that the trial and error method of adding
medications may prolong the time to response compared with
combining multiple drugs from the start. This sequential
approach is most appropriate for mildly active disease when
controlling symptoms quickly is less critical.
Combining multiple treatments at once, either with the
same drug by different delivery routes, or using two or
more drugs, may achieve a more prompt onset of action
and better efficacy than the sequential approach.
This is a common intuitive approach used by clinicians who have
seen the apparent benefit of using two or more treatments
at once, such as 5-aminosalicyclic (ASA, mesalamine) and
prednisone. Combination therapy is most commonly used
for moderate or severe disease, particularly if there is
urgency to getting the symptoms controlled promptly.
Downsides to the combination therapy are
the paucity of data from controlled trials to confirm the
benefits, difficulty identifying the offending drug if adverse
effects are noted, less compliance with more complicated
schedules, and higher costs.