Why is my ulcerative colitis worsening despite treatment?

Question

Hello doctor,

I am 33 years old, and I want to understand why ulcerative colitis seems to worsen in men in their 30s, as this appears to be happening to me. I was diagnosed about four years ago, and my pancolitis was manageable on Mesalamine 4 grams daily. However, in the last 18 months, I have had two severe flares requiring intravenous (IV) steroids.

My gastroenterologist recently added Azathioprine to my treatment, and my latest colonoscopy showed moderate to severe inflammation with a Mayo score of 8. My CRP is consistently elevated at around 18, and my hemoglobin has dropped to 10.2 during the last check.

My joints, especially my knees, have started hurting, which my doctor says might be an extraintestinal manifestation of ulcerative colitis. My testosterone levels were also low at 8.2 nmol/L, which my general physician says is unrelated, but I am not fully convinced.

The fatigue is so overwhelming that I had to significantly reduce my working hours. My father also had ulcerative colitis and underwent colectomy at 52 years of age, which concerns me.

Is there something biological or hormonal specific to men in their 30s that drives this aggressive progression?
Should I consider biologic therapy, such as Infliximab, at this stage instead of waiting further?

Kindly advise.

Answer 1

Hello,

Welcome to icliniq.com.

I have read the query and understand the concern.

The worsening described can occur in ulcerative colitis, but it is not specifically due to men reaching their 30s. This condition is a chronic immune-mediated disease characterized by periods of remission and relapse. In some individuals, inflammation may become more aggressive over time despite initial control with medications such as Mesalamine (5-aminosalicylic acid).

Factors such as genetic predisposition (family history), extensive disease (pancolitis), and persistently elevated inflammatory markers like C-reactive protein (CRP) can indicate a more active and progressive disease course.

A Mayo score of 8 on colonoscopy, along with repeated steroid-requiring flares, indicates moderate to severe disease. In such cases, escalation of therapy is usually appropriate. Medications such as Azathioprine are used to reduce immune activity and decrease steroid dependence; however, they may take eight to 12 weeks to show full effect.

If inflammation persists despite this, biologic therapy such as Infliximab or other targeted therapies is commonly considered and can help achieve deeper and sustained remission.

The knee pain described may represent peripheral arthritis, which is a known extraintestinal manifestation of ulcerative colitis and often improves when intestinal inflammation is controlled. Fatigue can be explained by chronic inflammation and anemia (hemoglobin 10.2 grams per deciliter). Low testosterone levels may contribute to fatigue, but are more commonly secondary to chronic illness, stress, or prior steroid use rather than a primary cause of disease worsening.

Management at this stage typically includes optimizing medical therapy, correcting anemia, monitoring nutritional status, and evaluating response to immunosuppressive or biologic therapy before considering surgical options. Colectomy is generally reserved for cases where the disease remains uncontrolled or complications develop.

I suggest you discuss early initiation of biologic therapy with your gastroenterologist, along with repeat evaluation of inflammatory markers, iron studies, and coordinated management of joint symptoms, possibly involving a rheumatologist. Many individuals achieve long-term remission with modern treatment approaches, even in cases where the disease becomes more active over time.

I hope you are satisfied with my answer. For further queries, you can consult me at iCliniq.

Thank you.