title: Review article: strategies for the management of chronic unremitting ulcerative colitis.
abstract: BACKGROUND
  Chronic active ulcerative colitis (UC) is associated with significant morbidity, loss of productivity, increased colorectal cancer risk and cost. Up to 18% of patients suffer chronic active disease, with 30% requiring colectomy at 10 years. The management remains challenging given the relatively few clinical trials in this area.
  
  
  OBJECTIVE
  To summarise the evidence regarding optimal management strategies for patients with chronic active UC of differing disease extents and degrees of treatment refractoriness.
  
  
  METHODS
  A literature search using the PubMed and Medline databases was performed. No time limit was set on article publication for inclusion.
  
  
  RESULTS
  The principles of management should focus on confirming disease activity, exclusion of alternative diagnoses, adherence and treatment escalation. Infliximab and topical tacrolimus are options in refractory proctitis, although the evidence for these therapies is limited. Both infliximab and adalimumab are effective in corticosteroid-refractory disease, although the proportions of patients achieving corticosteroid-free remission remain modest (24% at 30 weeks and 16.9% at 8 weeks respectively). Alternatives include ciclosporin and tacrolimus, and possibly methotrexate. Colectomy often leads to an improved quality of life; medical strategies unlikely to provide durable corticosteroid-free remission should not be pursued.
  
  
  CONCLUSIONS
  No current pharmacological treatment delivers mucosal healing in the majority of patients. Newer treatments such as vedolizumab and tofacitinib may represent valuable future therapies. Available medical options should be discussed with patients at every step of their management, with an honest appraisal of the evidence. Surgery should always be considered in patients with chronic refractory disease of any extent.
authors.affiliation: Centre for Digestive Diseases, Blizard Institute, Barts and the London School of Medicine, Queen Mary University, London, UK.
authors.forename: S J
authors.initials: SJ
authors.lastname: Mehta
authors.forename: A R
authors.initials: AR
authors.lastname: Silver
authors.forename: J O
authors.initials: JO
authors.lastname: Lindsay
mesh_terms: D000068879:Adalimumab; D000305:Adrenal Cortex Hormones / Q000627:therapeutic use*; D000911:Antibodies, Monoclonal / Q000627:therapeutic use; D061067:Antibodies, Monoclonal, Humanized / Q000627:therapeutic use*; D002986:Clinical Trials as Topic; D003082:Colectomy; D003093:Colitis, Ulcerative / Q000150:complications / Q000188:drug therapy* / Q000601:surgery; D016572:Cyclosporine / Q000627:therapeutic use; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D000069285:Infliximab; D012074:Remission Induction; D016559:Tacrolimus / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D000305:Adrenal Cortex Hormones; D000911:Antibodies, Monoclonal; D061067:Antibodies, Monoclonal, Humanized; D007166:Immunosuppressive Agents; D016572:Cyclosporine; D000069285:Infliximab; D000068879:Adalimumab; D016559:Tacrolimus