By Joo Hye Song, MD, PhD
Division of Gastroenterology, Department of Internal Medicine, Konkuk University Hospital

(Health Korea News, Seoul, South Korea) The treatment landscape for ulcerative colitis (UC) is rapidly changing. Therapeutic options that were once limited have expanded significantly with the emergence of biologic agents and small-molecule therapies, making personalized treatment strategies increasingly possible.

While the growing number of treatment options has made clinical decision-making more complex, it also provides an opportunity to select therapies that better align with individual patient characteristics, treatment goals, and quality-of-life considerations.

The first-line treatment for ulcerative colitis generally involves 5-aminosalicylic acid (5-ASA) agents, which remain effective for patients with proctitis and mild-to-moderate disease. However, when symptoms worsen or relapse occurs, corticosteroids may be introduced. Due to their potential adverse effects, long-term steroid therapy is not recommended.

For patients who develop steroid dependency or steroid-refractory disease, immunomodulators such as azathioprine and 6-mercaptopurine (6-MP) may be added. However, these therapies have a relatively slow onset of action, and many patients ultimately fail to achieve mucosal healing, a key treatment goal in ulcerative colitis, with conventional therapies alone.

For patients with inadequate responses to conventional treatments, various classes of advanced therapies are now available.

Anti-tumor necrosis factor (TNF) antibodies, including infliximab, adalimumab, and golimumab, have the longest clinical experience among biologic therapies. Vedolizumab, an anti-integrin antibody, has a gut-selective mechanism of action, which may reduce concerns regarding systemic immunosuppression and related adverse effects.

Interleukin (IL)-12/23 inhibitors such as ustekinumab and IL-23p19 inhibitors such as guselkumab offer favorable maintenance effects while minimizing infection-related concerns. Janus kinase (JAK) inhibitors, including tofacitinib, upadacitinib, and filgotinib, provide the convenience of oral administration, and some agents have demonstrated rapid onset of action in patients with moderate-to-severe disease. Sphingosine-1-phosphate (S1P) receptor modulators such as ozanimod have also emerged as oral treatment options for selected patients.

Each therapy differs in efficacy, safety profile, route of administration—including intravenous infusion, subcutaneous injection, and oral administration—and dosing frequency.

From a physician's perspective, treatment selection requires careful consideration of multiple factors, including disease extent, severity, comorbidities, previous treatment history, and the presence of extraintestinal manifestations. However, treatment decisions should not be made by physicians alone.

In the advanced therapy setting, several medications may be clinically appropriate for an individual patient. In such situations, patient preferences and lifestyle factors can significantly influence treatment selection.

Whether a therapy requires hospital visits for intravenous administration, allows self-injection through subcutaneous delivery at home, or can be taken orally may directly affect treatment adherence and patient satisfaction.

This is why shared decision-making has become increasingly important. Rather than physicians unilaterally determining treatment options, shared decision-making involves discussing the advantages and limitations of each therapy while incorporating the patient's individual priorities and values to reach the most appropriate choice.

Patients consider various factors when selecting treatment strategies. Working professionals may prefer oral therapies or self-administered injections that reduce the burden of hospital visits, while women planning pregnancy may prioritize therapies supported by extensive safety data.

Older patients who are vulnerable to infections or have a history of malignancy may benefit from therapies with more targeted mechanisms of action.

Accumulating evidence suggests that active patient participation in treatment decisions can improve medication adherence and contribute to better clinical outcomes and patient satisfaction.

The physician's role is not simply to prescribe medication but to present medically appropriate options and engage in meaningful discussions with patients. True treatment begins when physicians and patients work together to identify the most suitable therapeutic pathway.

Ulcerative colitis is a chronic disease that requires long-term management rather than a one-time cure. Actively participating in the treatment process and taking ownership of their care pathway can positively influence long-term clinical outcomes and quality of life.

About the Author

Joo Hye Song, MD, PhD, is a gastroenterologist specializing in inflammatory bowel diseases at Konkuk University Hospital in South Korea. She focuses on advanced therapy selection and long-term management of patients with ulcerative colitis and Crohn's disease. She applies patient-centered shared decision-making as a key principle of care to improve both treatment outcomes and quality of life.