Ulcerative colitis treatment options: what your GI doctor may discuss

There is no single treatment that works for everyone with ulcerative colitis. The right approach depends on how severe your symptoms are, where in the colon the inflammation is, how you have responded to previous treatments, and other factors like your overall health and insurance coverage.

This guide covers the main categories of UC treatment — what they are, how they work, and what questions to raise with your gastroenterologist.

Treatment goals

Before covering specific medications, it helps to understand what treatment is trying to achieve:

• Induction of remission: Controlling an active flare and returning symptoms to a manageable level
• Maintenance of remission: Keeping inflammation low and preventing future flares once remission is achieved
• Mucosal healing: Reducing visible inflammation in the colon lining to a level that reduces the risk of complications and flares

Your doctor will consider both induction and long-term maintenance when recommending treatment.

Aminosalicylates (5-ASAs)

Examples: Mesalamine (Asacol, Lialda, Pentasa, Apriso), sulfasalazine, balsalazide

How they work: 5-ASA medications work directly on the lining of the colon to reduce inflammation. They do not suppress the immune system the way biologics and immunosuppressants do — they work locally.

When they are used: First-line treatment for mild to moderate UC. Available as oral tablets, capsules, or rectal formulations (suppositories, enemas).

What to know: 5-ASAs are generally well-tolerated. They must be taken consistently — even during remission — to maintain their effect. Stopping them, even when feeling well, increases the risk of relapse. If mesalamine stops working, read our guide on what to do when mesalamine is not working.

Corticosteroids

Examples: Prednisone, prednisolone, budesonide (Entocort, Uceris)

How they work: Corticosteroids are powerful anti-inflammatory medications that reduce inflammation throughout the body (systemic steroids) or in a more targeted way (budesonide).

When they are used: For inducing remission during moderate to severe flares when 5-ASAs are not enough. Not used for long-term maintenance due to significant side effects with prolonged use.

What to know: Steroids work relatively quickly but are associated with side effects including bone density loss, weight gain, mood changes, high blood sugar, and increased infection risk. The goal is always to taper off steroids once remission is achieved and to avoid long-term dependence.

Immunomodulators

Examples: Azathioprine, 6-mercaptopurine (6-MP), methotrexate

How they work: These medications reduce immune system activity to decrease inflammation. They take weeks to months to reach full effect.

When they are used: Maintenance therapy, often combined with a biologic to improve its effectiveness and reduce the risk of antibody formation.

What to know: Regular blood monitoring is required because immunomodulators can affect white blood cell counts and liver function. They increase susceptibility to infections.

Biologic medications

Examples:

• TNF inhibitors: Infliximab (Remicade), adalimumab (Humira), golimumab (Simponi)
• Integrin inhibitors: Vedolizumab (Entyvio) — gut-selective
• IL-12/23 inhibitors: Ustekinumab (Stelara)
• IL-23 inhibitors: Mirikizumab (Omvoh), risankizumab (Skyrizi)

How they work: Biologics target specific proteins in the immune system that drive inflammation. Each biologic targets a different pathway, which is why some people respond to one but not another.

When they are used: Moderate to severe UC, or UC that has not responded adequately to 5-ASAs and/or corticosteroids.

What to know: Biologics are given by injection (self-administered at home) or by intravenous infusion at a clinic. Most require testing for tuberculosis before starting. They are generally well-tolerated but carry some increased risk of infection. Cost can be significant — most manufacturers offer patient assistance programs. For a deeper explanation, see our guide on biologics for ulcerative colitis.

JAK inhibitors

Examples: Tofacitinib (Xeljanz), upadacitinib (Rinvoq), filgotinib (Jyseleca — available outside US)

How they work: JAK inhibitors are oral small-molecule medications that block Janus kinase (JAK) enzymes inside cells, reducing the signaling that drives inflammation. Unlike biologics, they are taken as pills rather than injections or infusions.

When they are used: Moderate to severe UC, including in some patients who have not responded to biologic therapy.

What to know: JAK inhibitors have a rapid onset of action. They carry some specific risks including increased susceptibility to certain infections (particularly herpes zoster), elevated cholesterol, and — at higher doses or in older patients — cardiovascular considerations. Your doctor will discuss whether JAK inhibitors are appropriate for your profile. Read our full guide on JAK inhibitors for ulcerative colitis.

Surgery

When it is considered: Surgery is a treatment option for UC when medications are no longer effective, when complications arise (such as toxic megacolon, perforation, or colorectal cancer), or when a patient prefers to avoid long-term medication.

What it involves: The most common surgery for UC is a proctocolectomy with ileal pouch-anal anastomosis (IPAA), sometimes called a J-pouch procedure. This removes the colon and rectum and creates an internal pouch from the small intestine that functions as a new rectum. UC is effectively cured by this surgery since it removes the colon, but the procedure is major and requires significant recovery.

What to discuss with your doctor

Before your next appointment, consider asking:

• Is my current treatment getting my disease into remission — and if not, what are the next steps?
• Should I add rectal therapy to what I am currently taking?
• Am I a candidate for a biologic or JAK inhibitor?
• If I switch treatments, what monitoring will I need?
• What assistance programs are available to help with medication costs?
• Are there any clinical trials I should know about?

This content is for educational purposes only. Treatment decisions should be made with a licensed gastroenterologist who knows your full medical history.