Long-Term Maintenance Therapy for Ulcerative Colitis

Medically Reviewed by Melinda Ratini, MS, DO on May 29, 2022
5 min read

There’s no way to cure ulcerative colitis (UC). But there are now lots of ways to treat UC. The first goal of treatment is to get your UC into remission. When your UC is in remission, it means you shouldn’t see any blood in your stools. You shouldn’t need to find a bathroom more often than someone who doesn’t have UC. If a doctor looks at your colon, there shouldn’t be signs of UC there either.

To keep your UC in remission, you’ll need long-term maintenance therapy. So the second goal of UC treatment after you’re in remission is to do your best to make sure it stays that way.

The type of medicine you’ll take to keep your UC in remission will depend on how your UC responds to different treatments and how severe it is.

Common medicines for UC that’s mild to moderate are aminosalicylates that you take in oral form (tablets or capsules) or topical form (enema or suppository). They’re also called 5-ASAs. They help reduce the inflammation in the lining of the intestines. If your UC got better with this type of medicine or steroids, you might keep taking medicine with 5-ASA for your maintenance therapy.

There are lots of drugs in this group, including:

  • Balsalazide
  • Mesalamine
  • Olsalazine
  • Sulfasalazine

Other medicines for UC work by suppressing the immune system. They’re called immune modulators. Doctors usually don’t suggest these unless aminosalicylates and steroids aren’t working.

Medicines in this group include:

  • 6-mercaptopurine
  • Azathioprine
  • Cyclosporine
  • Tacrolimus

Azathioprine is sometimes used as maintenance therapy, but it comes with a risk for lymphoma. Cyclosporine and tacrolimus aren’t good long-term maintenance therapies because they are too toxic.

These are medications that target specific parts of the immune system to help reduce inflammation. They can be used to treat moderately to severely active UC and then can be continued as maintenance. These include:

  • Ozanimod
  • Tofacitinib
  • Upadacitinib

If your UC is more severe or doesn’t get better with other medicines, you might take a biologic for it. Biologics and biosimilars are genetically engineered proteins that target your immune system in different ways to treat UC or other conditions. Once your UC is in remission, you may keep taking your biologic medicine as a long-term maintenance therapy.

Biologics used to treat moderate or severe UC include:

  • Adalimumab
  • Golimumab
  • Infliximab
  • Ustekinumab
  • Vedolizumab

Corticosteroids, often just called steroids, suppress the immune system, too. They’re sometimes used to get a UC flare under control. But corticosteroids act on the whole immune system. They also have lots of side effects. Because of this, you shouldn’t take steroids long term, and doctors don’t use them as maintenance therapy.

Corticosteroids used to treat UC but not for long-term maintenance include:

  • Budesonide
  • Methylprednisolone
  • Prednisone
  • Prednisolone

Maintenance therapy can work well to keep your symptoms of UC at bay. But it probably doesn’t mean you’ll never have a flare again.

One study looked at how often people with UC relapsed while taking mesalamine for maintenance therapy. The study found that all patients had a relapse of symptoms or changes in their colon a doctor could see within 10 years. Most of them had a relapse sooner than that.

Another study looked at patients who took immune modulators or thiopurines (6-mercaptopurine, azathioprine) for maintenance of their UC. They found that about 40% to 50% hadn’t had worsening symptoms at 5-10 years. Some people taking thiopurines eventually did need surgery. Those who had taken steroids for their UC before more often did worse. Overall, the study showed that thiopurines can work well for long-term maintenance of UC. These medicines also may keep working for longer than biologics.

A review of studies on biologics for UC and Crohn’s disease found that they do a good job of allowing the surface of your intestines to heal. The studies suggest that some biologics work better than others for UC. Biologics and other treatments also can have side effects and risks.

One of the reasons long-term maintenance therapy doesn’t always work is that it’s hard for people to keep taking their medicine when they aren’t having symptoms. A study of people taking mesalamine for UC maintenance looked at what was more important: high versus low dose or taking the medicine on schedule.

The study found that it didn’t matter how much people took in terms of whether they’d flare or not. The most important thing was that people took their medicine. It might also help to take the medicine just once a day so it’s easier. Ask your doctor if this is a possibility for you. Whatever you can do to keep taking your medicine will help you to avoid a relapse of your UC.

If you stop taking your medicine, there’s obviously a better chance that your UC symptoms will come back. Most people with UC need maintenance therapy. Without maintenance therapy, it’s more likely you could need surgery in the future to treat your UC.

UC also comes with more risk that you’ll get abnormal cells in your intestines or colorectal cancer. Taking your maintenance medicine can help you lower these risks. There’s more data showing this with older medicines such as mesalamine than newer biologics.

Sometimes even if you’re taking your maintenance medicine as you should, it may stop working. This might happen more with biologics. Sometimes you might also have side effects that make your maintenance medicines hard to keep taking.

If you think your UC symptoms are back or you’re having troubling side effects, you’ll need to see your doctor to make sure you know what’s causing your symptoms and decide what to do next. They might be able to change how you’re taking your medicine to help it work better. Or you might need to switch to a different medicine. If approved medicines aren’t working for you, ask your doctor if there’s a clinical trial you could consider.