A 30-year-old female presents to your office as a new patient and requests a refill of sulfasalazine (Azulfidine) tablets for maintaining remission of her ulcerative colitis. The initial presentation of her disease was in her teenage years and involved inflammation of the entire colon. She was then started on sulfasalazine, which has worked well for controlling her symptoms. She had one flare when she ran out of medicine 7 years ago. She has not seen a gastroenterologist for many years.
Which one of the following is an appropriate management plan for this patient?
A.Refill her sulfasalazine and continue usual care unless symptoms recur
B.Attempt to gradually discontinue the sulfasalazine
C.Stop sulfasalazine and start azathioprine (Imuran)
D.Continue sulfasalazine and arrange for colonoscopy to screen for colon cancer
E.Refer to a colorectal surgeon to discuss colectomy
Ulcerative colitis (UC) is a lifelong condition that results in a waxing and waning autoimmune inflammation of the colon. Clinical symptoms are inadequate for assessing the need for ongoing therapy. For this reason, once a patient with UC has achieved remission with a specific medication, that medication should be continued indefinitely unless the disease resurfaces. Sulfasalazine is one of the most effective agents for this purpose, is usually well tolerated, and is considered first-line therapy for ulcerative colitis. There is no apparent reason to consider a higher order of therapy (azathioprine) in this patient or to refer her for colectomy. Patients with UC who have had a history of moderate or extensive involvement of the colon, however, are at markedly increased risk for the development of colorectal cancer. Current guidelines recommend beginning screening colonoscopy 10 years after the initial diagnosis and continuing every 2–5 years, with the interval based on the findings.
Ref: Adams SM, Bornemann PH: Ulcerative colitis. Am Fam Physician 2013;87(10):699-705. 2) Ford AC, Moayyedi P, Hanauer SB: Ulcerative colitis. BMJ 2013;346:f432.