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Ulcerative colitis (UC) is a chronic inflammatory disorder of the GI tract of unknown etiology. It most commonly affects teenagers and young adults, but can occur in any age group. It has a prevalence of 238 per 100,000 in the US adult population and an incidence rate of 2.2-14.3 cases per 100,000 person-years in North America [1]. The clinical course for patients with UC is one that follows a relapsing and remitting course, with symptoms of bloody diarrhea, rectal urgency and abdominal pain [2]. Diffuse mucosal inflammation involves the rectum in 95% of cases, and may extend proximally, involving parts, or all, of the colon [3]. In addition, patients may suffer from extraintestinal manifestations of UC, including episcleritis, scleritis, uveitis, peripheral arthropathies of small and large joints, erythema nodosum, pyoderma gangrenosum, axial arthropathies, sacroilitis, ankylosing spondylitis and primary sclerosing cholangitis. There is an increased risk for colorectal cancer (CRC) with longstanding inflammation, with risks reported as being 0.5-1% per year [4].
Treatment options for patients with UC involve either chronic medical therapy to suppress intestinal inflammation or a colectomy (surgical removal of the colon) to remove the diseased organ [5]. Medical options are divided into agents used to achieve a clinical response and remission (induction agents), and those used to maintain clinical remission (maintenance agents), although some agents can be used for both situations. Since there is no known 'cure'for UC, most patients take maintenance medical therapy to prevent disease relapse. Colectomy is reserved for those with disease refractory to medical therapy or those who develop complications. Medical management usually involves a 'step-up'approach, starting with topical or oral agents, and ascending to more complex agents, with risk of more serious adverse effects, in those who do not respond to first-line agents [2].
The type and formulation of therapy recommended for patients with UC is dependent on both the location of the disease and the degree of severity. In some patients, the inflammation is limited to the rectum only (distal), but other affected individuals have colonic disease that extends along the length of much of the colon (extensive). Topical (rectal) therapy is the starting point for patients with disease limited to the left colon, with oral therapy added on in patients with more extensive disease...