When to consider biologic therapies to cure ulcerative colitis?

Question

Hello doctor,

I was diagnosed with ulcerative colitis two years ago and am currently taking oral Mesalamine tablets.

My recent colonoscopy showed mild inflammation limited to the sigmoid colon, and my CRP level is 8 mg/L.

Despite regular medication, I still experience three to four loose stools per day with occasional mild bleeding.

So my concerns are:

Does this indicate that I am not in complete remission yet?
Would adding or switching to rectal mesalamine (suppositories or enemas) help achieve better healing since the disease is limited to the distal colon?
Are there certain foods that can trigger symptoms or flare-ups even if they are generally considered healthy, such as milk, oats, or high-fiber foods?
I have also read about biologic injections used in ulcerative colitis. Under what circumstances are biologic therapies considered necessary?
Lastly, should I be monitoring fecal calprotectin levels regularly to assess disease activity and response to treatment?

Kindly help.

Answer 1

Hello,

Welcome to icliniq.com.

I have read your query and understand your concerns.

With three to four loose stools per day, intermittent rectal bleeding, and mild sigmoid inflammation, this does not represent full remission. The therapeutic target is symptom control along with normal or near-normal mucosal healing.

A CRP (C-reactive protein) level of 8 mg/L is only mildly elevated and may not reliably reflect colonic disease activity; therefore, symptoms and endoscopic findings are more informative.

If the disease is predominantly sigmoid or left-sided, adding topical Mesalamine is beneficial. Mesalamine suppositories are most effective for rectal involvement, while Mesalamine enemas reach the sigmoid and descending colon and often achieve faster mucosal healing, particularly when combined with oral Mesalamine.

If rectal bleeding persists despite optimized Mesalamine therapy, a short course of topical corticosteroid foam or enema may be used.

Dietary triggers are highly individualized. Some patients experience worsening of symptoms with milk or lactose, high-fat foods, alcohol, very spicy foods, or large amounts of insoluble fiber.

Although generally considered healthy, foods such as oats may increase bloating or loose stools in certain individuals. An individualized food–symptom diary is preferable to broad dietary restrictions.

Biologic agents or small-molecule therapies are considered in patients with moderate to severe disease, steroid dependence, frequent relapses, or persistent inflammation despite optimized mesalamine with or without corticosteroids.

Fecal calprotectin is a valuable noninvasive marker for monitoring intestinal inflammation, predicting relapse, and distinguishing inflammatory disease activity from IBS (irritable bowel syndrome)-like symptoms.

Regular monitoring of fecal calprotectin, alongside symptom assessment and periodic endoscopic evaluation as clinically indicated, is recommended.

I hope this information is helpful, and I would greatly appreciate your feedback.

Thanks and regards.