I have long-standing ulcerative colitis. I have used Carafate during mild flare-ups and it seems to help. However, my local doctors think Carafate is not an effective treatment. After my last colonoscopy, the doctor prescribed 6MP, which I understand is an anti-leukemia drug. Isn't this treatment harsh? I don't really want to shoot down my immune system and leave myself open to infections and other side effects to treat a mild flare-up.

F.

Ulcerative colitis is a chronic inflammatory disorder of the lining of the colon characterized by bloody diarrhea, weight loss, abdominal cramping and rectal pain. Although the exact cause of ulcerative colitis is still unknown, we know that the immune system is involved. Thus, medications intended to affect various parts of the immune system are used to treat this condition.

First-line medications for ulcerative colitis commonly include those with the compound mesalamine in them, including Pentasa and Asacol. Mesalamine is effective in oral as well as enema forms and can bring active colitis into remission, usually over a period of weeks to months. Mesalamine is also effective in preventing relapse of the colitis after remission has been achieved. These medications are typically used in mild to moderate flares of the disease, when hospitalization is not needed.

In cases where mesalamine alone is not effective in treating the colitis, or in more severe cases, steroids (oral or intravenous) are given. Steroids are at least as effective as mesalamine and can bring the disease into remission much more quickly. The drawbacks to long-term steroid use are their inability to keep the disease in remission and their side effects. Steroid-related side effects can be debilitating and include osteoporosis and fractures, hip necrosis, diabetes and cataracts.

A small subgroup of patients with ulcerative colitis either do not completely respond to steroids or are unable to decrease the dose without the colitis becoming worse. In these cases, there are two main options: 6MP or surgical removal of the colon. Although surgery can cure ulcerative colitis, many patients are hesitant to have this surgery. They may not have severe disease that is interfering with their lifestyle, or they may be concerned about the psychological aftereffects of the surgery.

6MP is a medication that suppresses the function of certain immune cells, called T lymphocytes. As you mentioned, the drug is used in cancer chemotherapy. However, in most patients, it is a very safe and effective drug for ulcerative colitis. Studies with 6MP show that patients can reduce or eliminate their steroids, while keeping the disease in remission. 6MP takes about three to four months to achieve its effect, so steroid doses are reduced slowly. There are potential side effects with 6MP, occurring in 5 percent of patients. The side effects include pancreatitis, rashes and low blood counts. So, patients on 6MP need close follow-up with their gastroenterologist, especially early in therapy.

In your case, I wonder if you are on a regular dose of a mesalamine drug as maintenance for your ulcerative colitis. This is the most commonly used medication in patients who have mild disease or flare-ups. I am unaware of Carafate (sucralfate) having a significant effect on the course of ulcerative colitis and have not used this medication in treating patients with this disease. If you have very frequent flare-ups, especially if you require steroids at those times, then 6MP would be a good alternative. You should discuss your options at length with your gastroenterologist.