Editing Ulcerative colitis (section)

===Medication===
The first-line maintenance medication for ulcerative colitis in remission is [[mesalazine]] (also known as mesalamine or 5-ASA).<ref name="Ham Moss 2012 pp. 113–123">{{cite journal | last1=Ham | first1=Maggie | last2=Moss | first2=Alan C | title=Mesalamine in the treatment and maintenance of remission of ulcerative colitis | journal=Expert Review of Clinical Pharmacology | volume=5 | issue=2 | date=2012 | issn=1751-2433 | pmid=22390554 | pmc=3314328 | doi=10.1586/ecp.12.2 | pages=113–123}}</ref><ref name="Raine Bonovas Burisch Kucharzik 2022 pp. 2–17">{{cite journal | last1=Raine | first1=Tim | last2=Bonovas | first2=Stefanos | last3=Burisch | first3=Johan | last4=Kucharzik | first4=Torsten | last5=Adamina | first5=Michel | last6=Annese | first6=Vito | last7=Bachmann | first7=Oliver | last8=Bettenworth | first8=Dominik | last9=Chaparro | first9=Maria | last10=Czuber-Dochan | first10=Wladyslawa | last11=Eder | first11=Piotr | last12=Ellul | first12=Pierre | last13=Fidalgo | first13=Catarina | last14=Fiorino | first14=Gionata | last15=Gionchetti | first15=Paolo | last16=Gisbert | first16=Javier P | last17=Gordon | first17=Hannah | last18=Hedin | first18=Charlotte | last19=Holubar | first19=Stefan | last20=Iacucci | first20=Marietta | last21=Karmiris | first21=Konstantinos | last22=Katsanos | first22=Konstantinos | last23=Kopylov | first23=Uri | last24=Lakatos | first24=Peter L | last25=Lytras | first25=Theodore | last26=Lyutakov | first26=Ivan | last27=Noor | first27=Nurulamin | last28=Pellino | first28=Gianluca | last29=Piovani | first29=Daniele | last30=Savarino | first30=Edoardo | last31=Selvaggi | first31=Francesco | last32=Verstockt | first32=Bram | last33=Spinelli | first33=Antonino | last34=Panis | first34=Yves | last35=Doherty | first35=Glen | title=ECCO Guidelines on Therapeutics in Ulcerative Colitis: Medical Treatment | journal=Journal of Crohn's and Colitis | volume=16 | issue=1 | date=28 January 2022 | issn=1873-9946 | doi=10.1093/ecco-jcc/jjab178 | pages=2–17| pmid=34635919 }}</ref> For patients with active disease limited to the [[Descending colon|left colon]] (descending colon) or proctitis, mesalazine is also the first-line agent, and a combination of [[suppositories]] and oral mesalazine may be tried. Adding [[corticosteroid]]s such as [[prednisone]] is also common in active disease, especially if remission is not achieved through mesalazine monotherapy,<ref name="Ham Moss 2012 pp. 113–123"/><ref name="Raine Bonovas Burisch Kucharzik 2022 pp. 2–17"/> but they are not used in long-term treatment as their risks then outweigh their benefits. Immunosuppressive medications such as [[azathioprine]] and [[Biopharmaceutical|biological agent]]s such as [[infliximab]], [[adalimumab]], [[ustekinumab]], [[vedolizumab]], or [[risankizumab]] are given in severe disease or if a patient cannot achieve remission with mesalazine and corticosteroids.<ref name=AGAClinicalPractice2020>{{cite journal | vauthors = Feuerstein JD, Isaacs KL, Schneider Y, Siddique SM, Falck-Ytter Y, Singh S | title = AGA Clinical Practice Guidelines on the Management of Moderate to Severe Ulcerative Colitis | journal = Gastroenterology | volume = 158 | issue = 5 | pages = 1450–1461 | date = April 2020 | pmid = 31945371 | pmc = 7175923 | doi = 10.1053/j.gastro.2020.01.006 | doi-access = free }}</ref><ref name="Skyrizi FDA label">{{cite web | title=Skyrizi- risankizumab-rzaa kit | website=DailyMed | date=18 June 2024 | url=https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=7148c8eb-b39e-e20a-6494-a6df82392858 | access-date=2 November 2024}}</ref> As an alternative to mesalazine, one of its [[prodrug]]s such as [[sulfasalazine]] may be chosen for treatment of active disease or maintenance therapy,<ref name="Sandborn 2002 pp. 2939–2941">{{cite journal | last=Sandborn | first=W | title=Rational selection of oral 5-aminosalicylate formulations and prodrugs for the treatment of ulcerative colitis | journal=The American Journal of Gastroenterology | volume=97 | issue=12 | date=2002 | doi=10.1016/S0002-9270(02)05509-0 | pages=2939–2941| pmid=12492172 }}</ref> but the prodrugs have greater potential for serious side effects and have not been demonstrated to be superior to mesalazine in large trials.<ref name="Ko Singh Feuerstein Falck-Ytter 2019 pp. 748–764">{{cite journal | last1=Ko | first1=Cynthia W. | last2=Singh | first2=Siddharth | last3=Feuerstein | first3=Joseph D. | last4=Falck-Ytter | first4=Corinna | last5=Falck-Ytter | first5=Yngve | last6=Cross | first6=Raymond K. | last7=Crockett | first7=Seth | last8=Falck-Ytter | first8=Yngve | last9=Feuerstein | first9=Joseph | last10=Flamm | first10=Steven | last11=Inadomi | first11=John | last12=Ko | first12=Cynthia | last13=Muniraj | first13=Thiruvengadam | last14=O’Shea | first14=Robert | last15=Pandolfino | first15=John | last16=Patel | first16=Amit | last17=Sharaf | first17=Ravi | last18=Siddique | first18=Shazia | last19=Su | first19=Grace | last20=Wang | first20=Kenneth | last21=Weizman | first21=Adam | title=AGA Clinical Practice Guidelines on the Management of Mild-to-Moderate Ulcerative Colitis | journal=Gastroenterology | volume=156 | issue=3 | date=2019 | pmid=30576644 | pmc=6858922 | doi=10.1053/j.gastro.2018.12.009 | pages=748–764}}</ref>

A formulation of [[budesonide]] was approved by the U.S. [[Food and Drug Administration]] (FDA) for treatment of active ulcerative colitis in January 2013.<ref>{{cite news |title=FDA approves Uceris as ulcerative colitis treatment |url=https://www.healio.com/news/gastroenterology/20130115/santarus_10_3928_1081_597x_20130101_15_997579 |work=Healio Gastroenterology |date=15 January 2013}}</ref><ref>{{cite web |title=UCERIS (budesonide) extended release tablets label |url=https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/203634s000lbl.pdf |archive-url=https://web.archive.org/web/20150906040455/http://www.accessdata.fda.gov/drugsatfda_docs/label/2013/203634s000lbl.pdf |url-status=dead |archive-date=6 September 2015 |publisher=FDA}}</ref> In 2018, [[tofacitinib]] was approved for treatment of moderately to severely active ulcerative colitis in the United States, the first oral medication indicated for long term use in this condition.<ref>{{cite press release|url=https://www.fda.gov/news-events/press-announcements/fda-approves-new-treatment-moderately-severely-active-ulcerative-colitis |archive-url=https://web.archive.org/web/20191215062502/https://www.fda.gov/news-events/press-announcements/fda-approves-new-treatment-moderately-severely-active-ulcerative-colitis |url-status=dead |archive-date=15 December 2019 |title=FDA approves new treatment for moderately to severely active ulcerative colitis|website=U.S. [[Food and Drug Administration]] (FDA) |date=30 May 2018 |access-date=31 May 2018}}</ref> The evidence on [[methotrexate]] does not show a benefit in producing remission in people with ulcerative colitis.<ref>{{cite journal | vauthors = Chande N, Wang Y, MacDonald JK, McDonald JW | title = Methotrexate for induction of remission in ulcerative colitis | journal = The Cochrane Database of Systematic Reviews | volume = 8 | issue = 8 | pages = CD006618 | date = August 2014 | pmid = 25162749 | pmc = 6486224 | doi = 10.1002/14651858.CD006618.pub3 }}</ref> [[Cyclosporine]] is effective for severe UC<ref name=AGAClinicalPractice2020 /> and [[tacrolimus]] has also shown benefits.<ref>{{cite journal | vauthors = Krishnamoorthy R, Abrams KR, Guthrie N, Samuel S, Thomas T |s2cid=74798482 |title=PWE-237 Ciclosporin in acute severe ulcerative colitis: a meta-analysis |journal=Gut |date=28 May 2012 |volume=61 |issue=Suppl 2 |pages=A394.2–A394 |doi=10.1136/gutjnl-2012-302514d.237|doi-access=free }}</ref><ref>{{cite journal | vauthors = Ogata H, Kato J, Hirai F, Hida N, Matsui T, Matsumoto T, Koyanagi K, Hibi T | title = Double-blind, placebo-controlled trial of oral tacrolimus (FK506) in the management of hospitalized patients with steroid-refractory ulcerative colitis | journal = Inflammatory Bowel Diseases | volume = 18 | issue = 5 | pages = 803–808 | date = May 2012 | pmid = 21887732 | doi = 10.1002/ibd.21853 | s2cid = 1294555 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Lichtiger S, Present DH, Kornbluth A, Gelernt I, Bauer J, Galler G, Michelassi F, Hanauer S | title = Cyclosporine in severe ulcerative colitis refractory to steroid therapy | journal = The New England Journal of Medicine | volume = 330 | issue = 26 | pages = 1841–1845 | date = June 1994 | pmid = 8196726 | doi = 10.1056/NEJM199406303302601 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Weisshof R, Ollech JE, El Jurdi K, Yvellez OV, Cohen RD, Sakuraba A, Dalal S, Pekow J, Rubin DT | title = Ciclosporin Therapy After Infliximab Failure in Hospitalized Patients With Acute Severe Colitis is Effective and Safe | journal = Journal of Crohn's & Colitis | volume = 13 | issue = 9 | pages = 1105–1110 | date = September 2019 | pmid = 30726894 | pmc = 7327272 | doi = 10.1093/ecco-jcc/jjz032 }}</ref> [[Etrasimod]] was approved for medical use in the United States in October 2023.<ref>{{cite press release | title=U.S. FDA Approves Pfizer's Velsipity for Adults with Moderately to Severely Active Ulcerative Colitis (UC) | publisher=Pfizer | via=Business Wire | date=13 October 2023 | url=https://www.businesswire.com/news/home/20231012073213/en/ | access-date=13 October 2023}}</ref>

====Aminosalicylates====
Sulfasalazine has been a major agent in the therapy of mild to moderate ulcerative colitis for over 50 years. In 1977, it was shown that 5-aminosalicylic acid (5-ASA, [[mesalazine]]/mesalamine) was the therapeutically active component in sulfasalazine.<ref>{{cite journal | vauthors = Azad Khan AK, Piris J, Truelove SC | title = An experiment to determine the active therapeutic moiety of sulphasalazine | journal = Lancet | volume = 2 | issue = 8044 | pages = 892–895 | date = October 1977 | pmid = 72239 | doi = 10.1016/s0140-6736(77)90831-5 | s2cid = 44785199 }}</ref>  Many 5-ASA drugs have been developed with the aim of delivering the active compound to the large intestine to maintain therapeutic efficacy but with reduction of the side effects associated with the sulfapyridine moiety in sulfasalazine.  Oral 5-ASA drugs are particularly effective in inducing and in maintaining remission in mild to moderate ulcerative colitis.<ref>{{cite journal | vauthors = Murray A, Nguyen TM, Parker CE, Feagan BG, MacDonald JK | title = Oral 5-aminosalicylic acid for induction of remission in ulcerative colitis | journal = The Cochrane Database of Systematic Reviews | volume = 2020 | issue = 8 | pages = CD000543 | date = August 2020 | pmid = 32786164 | pmc = 8189994 | doi = 10.1002/14651858.CD000543.pub5 }}</ref><ref>{{cite journal | vauthors = Murray A, Nguyen TM, Parker CE, Feagan BG, MacDonald JK | title = Oral 5-aminosalicylic acid for maintenance of remission in ulcerative colitis | journal = The Cochrane Database of Systematic Reviews | volume = 2020 | issue = 8 | pages = CD000544 | date = August 2020 | pmid = 32856298 | pmc = 8094989 | doi = 10.1002/14651858.CD000544.pub5 }}</ref>  Rectal suppository, foam or liquid enema formulations of 5-ASA are used for colitis affecting the rectum, sigmoid or descending colon, and have been shown to be effective especially when combined with oral treatment.<ref>{{cite journal | vauthors = Marshall JK, Thabane M, Steinhart AH, Newman JR, Anand A, Irvine EJ | title = Rectal 5-aminosalicylic acid for maintenance of remission in ulcerative colitis | journal = The Cochrane Database of Systematic Reviews | volume = 11 | pages = CD004118 | date = November 2012 | pmid = 23152224 | doi = 10.1002/14651858.CD004118.pub2 | pmc = 11972843 }}</ref>

====Biologics====
Biologic treatments such as the [[TNF inhibitor]]s [[infliximab]], [[adalimumab]], and [[golimumab]] are commonly used to treat people with UC who are no longer responding to corticosteroids. [[Tofacitinib]] and [[vedolizumab]] can also produce good clinical remission and response rates in UC.<ref name=Hir2015/> Biologics may be used early in treatment (step down approach), or after other treatments have failed to induce remission (step up approach); the strategy should be individualized.<ref>{{cite journal | vauthors = Salahudeen MS | title = A review of current evidence allied to step-up and top-down medication therapy in inflammatory bowel disease | journal = Drugs of Today | volume = 55 | issue = 6 | pages = 385–405 | date = June 2019 | pmid = 31250843 | doi = 10.1358/dot.2019.55.6.2969816 | s2cid = 195763151 }}</ref>

Unlike aminosalicylates, biologics can cause serious side effects such as an increased risk of developing extra-intestinal cancers,<ref name=AxelradLichtiger2016>{{cite journal | vauthors = Axelrad JE, Lichtiger S, Yajnik V | title = Inflammatory bowel disease and cancer: The role of inflammation, immunosuppression, and cancer treatment | journal = World Journal of Gastroenterology | volume = 22 | issue = 20 | pages = 4794–4801 | date = May 2016 | pmid = 27239106 | pmc = 4873872 | doi = 10.3748/wjg.v22.i20.4794 | type = Review | doi-access = free }}</ref> [[heart failure]]; and weakening of the immune system, resulting in a [[Immunodeficiency|decreased ability of the immune system to clear infections]] and reactivation of latent infections such as [[tuberculosis]]. For this reason, people on these treatments are closely monitored and are often tested for hepatitis and tuberculosis annually.<ref>{{cite journal | vauthors = Stevens JP, Ballengee CR, Chandradevan R, Thompson AB, Schoen BT, Kugathasan S, Sauer CG | title = Performance of Interferon-Gamma Release Assays for Tuberculosis Screening in Pediatric Inflammatory Bowel Disease | journal = Journal of Pediatric Gastroenterology and Nutrition | volume = 69 | issue = 4 | pages = e111–e116 | date = October 2019 | pmid = 31261245 | doi = 10.1097/MPG.0000000000002428 | s2cid = 195771593 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Lee CK, Wong SH, Lui G, Tang W, Tam LS, Ip M, Hung E, Chen M, Wu JC, Ng SC | title = A Prospective Study to Monitor for Tuberculosis During Anti-tumour Necrosis Factor Therapy in Patients With Inflammatory Bowel Disease and Immune-mediated Inflammatory Diseases | journal = Journal of Crohn's & Colitis | volume = 12 | issue = 8 | pages = 954–962 | date = July 2018 | pmid = 29757355 | doi = 10.1093/ecco-jcc/jjy057 | s2cid = 21673794 | doi-access = free }}</ref>

Etrasimod, a once-daily oral sphingosine 1-phosphate (S1P) receptor modulator that selectively activates S1P receptor subtypes 1, 4, and 5 with no detectable activity on S1P 2 or 3, is in development for treatment of immune-mediated diseases, including ulcerative colitis, and was shown in 2 randomized trials to be effective and well tolerated as induction and maintenance therapy in patients with moderately to severely active ulcerative colitis.<ref>{{cite journal |last1=Sandborn |first1=William J. |last2=Vermeire |first2=Séverine |last3=Peyrin-Biroulet |first3=Laurent |last4=Dubinsky |first4=Marla C. |last5=Panes |first5=Julian |last6=Yarur |first6=Andres |last7=Ritter |first7=Timothy |last8=Baert |first8=Filip |last9=Schreiber |first9=Stefan |last10=Sloan |first10=Sheldon |last11=Cataldi |first11=Fabio |last12=Shan |first12=Kevin |last13=Rabbat |first13=Christopher J. |last14=Chiorean |first14=Michael |last15=Wolf |first15=Douglas C. |date=8 April 2023 |title=Etrasimod as induction and maintenance therapy for ulcerative colitis (ELEVATE): two randomised, double-blind, placebo-controlled, phase 3 studies |journal=The Lancet |language=English |volume=401 |issue=10383 |pages=1159–1171 |doi=10.1016/S0140-6736(23)00061-2 |issn=0140-6736 |pmid=36871574|s2cid=257286271 |doi-access=free }}</ref>

====Nicotine====
Unlike [[Crohn's disease]], ulcerative colitis has a lesser chance of affecting smokers than non-smokers.<ref>{{cite journal | vauthors = Calkins BM | title = A meta-analysis of the role of smoking in inflammatory bowel disease | journal = Digestive Diseases and Sciences | volume = 34 | issue = 12 | pages = 1841–1854 | date = December 1989 | pmid = 2598752 | doi = 10.1007/BF01536701 | s2cid = 5775169 }}</ref><ref>{{cite journal | vauthors = Lakatos PL, Szamosi T, Lakatos L | title = Smoking in inflammatory bowel diseases: good, bad or ugly? | journal = World Journal of Gastroenterology | volume = 13 | issue = 46 | pages = 6134–6139 | date = December 2007 | pmid = 18069751 | pmc = 4171221 | doi = 10.3748/wjg.13.6134 | doi-access = free }}</ref> In select individuals with a history of previous tobacco use, resuming low dose smoking may improve signs and symptoms of active ulcerative colitis,<ref>{{cite journal | vauthors = Calabrese E, Yanai H, Shuster D, Rubin DT, Hanauer SB | title = Low-dose smoking resumption in ex-smokers with refractory ulcerative colitis | journal = Journal of Crohn's & Colitis | volume = 6 | issue = 7 | pages = 756–762 | date = August 2012 | pmid = 22398093 | doi = 10.1016/j.crohns.2011.12.010 | doi-access = free }}</ref> but it is not recommended due to the overwhelmingly negative [[health effects of tobacco]].<ref name=Cosnes2004>{{cite journal | vauthors = Cosnes J | title = Tobacco and IBD: relevance in the understanding of disease mechanisms and clinical practice | journal = Best Practice & Research. Clinical Gastroenterology | volume = 18 | issue = 3 | pages = 481–496 | date = June 2004 | pmid = 15157822 | doi = 10.1016/j.bpg.2003.12.003 }}</ref> Studies using a [[transdermal nicotine]] patch have shown clinical and histological improvement.<ref>{{cite journal | vauthors = Guslandi M | title = Nicotine treatment for ulcerative colitis | journal = British Journal of Clinical Pharmacology | volume = 48 | issue = 4 | pages = 481–484 | date = October 1999 | pmid = 10583016 | pmc = 2014383 | doi = 10.1046/j.1365-2125.1999.00039.x | df = dmy-all }}</ref> In one double-blind, placebo-controlled study conducted in the [[United Kingdom]], 48.6% of people with UC who used the nicotine patch, in conjunction with their standard treatment, showed complete resolution of symptoms. Another randomized, double-blind, placebo-controlled, single-center clinical trial conducted in the [[United States]] showed that 39% of people who used the patch showed significant improvement, versus 9% of those given a placebo.<ref>{{cite journal | vauthors = Sandborn WJ, Tremaine WJ, Offord KP, Lawson GM, Petersen BT, Batts KP, Croghan IT, Dale LC, Schroeder DR, Hurt RD | title = Transdermal nicotine for mildly to moderately active ulcerative colitis. A randomized, double-blind, placebo-controlled trial | journal = Annals of Internal Medicine | volume = 126 | issue = 5 | pages = 364–371 | date = March 1997 | pmid = 9054280 | doi = 10.7326/0003-4819-126-5-199703010-00004 | s2cid = 25745900 }}</ref> However, nicotine therapy is generally not recommended due to side effects and inconsistent results.<ref>{{cite journal | vauthors = Bonapace CR, Mays DA | title = The effect of mesalamine and nicotine in the treatment of inflammatory bowel disease | journal = The Annals of Pharmacotherapy | volume = 31 | issue = 7–8 | pages = 907–913 | date = 1997 | pmid = 9220055 | doi = 10.1177/106002809703100719 | s2cid = 24122049 }}</ref><ref>{{cite journal | vauthors = Kennedy LD | title = Nicotine therapy for ulcerative colitis | journal = The Annals of Pharmacotherapy | volume = 30 | issue = 9 | pages = 1022–1023 | date = September 1996 | pmid = 8876866 }}</ref><ref>{{cite journal | vauthors = Rubin DT, Hanauer SB | title = Smoking and inflammatory bowel disease | journal = European Journal of Gastroenterology & Hepatology | volume = 12 | issue = 8 | pages = 855–862 | date = August 2000 | pmid = 10958212 | doi = 10.1097/00042737-200012080-00004 }}</ref>

====Iron supplementation====
The gradual loss of blood from the gastrointestinal tract, as well as chronic inflammation, often leads to anemia, and professional guidelines suggest routinely monitoring for anemia with blood tests repeated every three months in active disease and annually in quiescent disease.<ref name="ReferenceA">{{cite journal | vauthors = Goddard AF, James MW, McIntyre AS, Scott BB | title = Guidelines for the management of iron deficiency anaemia | journal = Gut | volume = 60 | issue = 10 | pages = 1309–1316 | date = October 2011 | pmid = 21561874 | doi = 10.1136/gut.2010.228874 | collaboration = British Society of Gastroenterology | doi-access = free }}</ref> Adequate disease control usually improves anemia of chronic disease, but iron deficiency anemia should be treated with iron supplements. The form in which treatment is administered depends both on the severity of the anemia and on the guidelines that are followed. Some advise that [[parenteral iron]] be used first because people respond to it more quickly, it is associated with fewer gastrointestinal side effects, and it is not associated with compliance issues.<ref name="pmid17985376">{{cite journal | vauthors = Gasche C, Berstad A, Befrits R, Beglinger C, Dignass A, Erichsen K, Gomollon F, Hjortswang H, Koutroubakis I, Kulnigg S, Oldenburg B, Rampton D, Schroeder O, Stein J, Travis S, Van Assche G | title = Guidelines on the diagnosis and management of iron deficiency and anemia in inflammatory bowel diseases | journal = Inflammatory Bowel Diseases | volume = 13 | issue = 12 | pages = 1545–1553 | date = December 2007 | pmid = 17985376 | doi = 10.1002/ibd.20285 | doi-access = free }}</ref> Others require oral iron to be used first, as people eventually respond and many will tolerate the side effects.<ref name="ReferenceA"/><ref name=Mowat2011>{{cite journal | vauthors = Mowat C, Cole A, Windsor A, Ahmad T, Arnott I, Driscoll R, Mitton S, Orchard T, Rutter M, Younge L, Lees C, Ho GT, Satsangi J, Bloom S | title = Guidelines for the management of inflammatory bowel disease in adults | journal = Gut | volume = 60 | issue = 5 | pages = 571–607 | date = May 2011 | pmid = 21464096 | doi = 10.1136/gut.2010.224154 | s2cid = 8269837 }}</ref>

====Anticholinergics====
[[Anticholinergic]] drugs, more specifically [[muscarinic antagonist]]s, are sometimes used to treat abdominal cramps in connection with ulcerative colitis through their calming effect on colonic [[peristalsis]] (reducing both amplitude and frequency) and [[Muscle tone|intestinal tone]].<ref name="Can Med Assoc J p. ">{{cite journal | title=Drugs for Ulcerative Colitis | journal=Canadian Medical Association Journal | date=1964 | publisher=Can Med Assoc J | volume=91 | issue=21 | issn=0008-4409 | pmid=14229762 | author1=O'SULLIVAN PM | pages=1123–1124 | pmc=1928363 }}</ref><ref name="Camilleri Szarka 2008 pp. 1108–1156">{{cite book | last1=Camilleri | first1=Michael | last2=Szarka | first2=Lawrence | title=Textbook of Gastroenterology | chapter=Dysmotility of the Small Intestine and Colon | publisher=Wiley | date=14 November 2008 | isbn=978-1-4051-6911-0 | doi=10.1002/9781444303254.ch47 | pages=1108–1156| s2cid=83791469 }}</ref> Some medical authorities suggest over-the-counter anticholinergic drugs as potential helpful treatments for abdominal cramping in mild ulcerative colitis.<ref name="Amanda Fernandez, OMS IV Ronald Januchowski, DO, FACOFP 2020 pp. 10–16">{{cite journal | author=Amanda Fernandez, OMS IV | author2=Ronald Januchowski, DO, FACOFP | title=Osteopathic Primary Care Treatment Options for Ulcerative Colitis | journal=Osteopathic Family Physician | volume=12 | issue=3 | date=30 April 2020 | issn=1877-573X | doi=10.33181/12031 | pages=10–16| s2cid=219029672 }}</ref> However, their use is contraindicated especially in moderate to severe disease states because of the potential for anticholinergic treatment to induce [[toxic megacolon]] in patients with colonic inflammation.<ref name="Sedano Quera Simian Yarur 2019 pp. 943–955">{{cite journal | last1=Sedano | first1=Rocío | last2=Quera | first2=Rodrigo | last3=Simian | first3=Daniela | last4=Yarur | first4=Andres J. | title=An approach to acute severe ulcerative colitis | journal=Expert Review of Gastroenterology & Hepatology | publisher=Informa UK Limited | volume=13 | issue=10 | date=3 October 2019 | issn=1747-4124 | doi=10.1080/17474124.2019.1681974 | pages=943–955| pmid=31648574 | s2cid=204891274 }}</ref> Toxic megacolon is a state in which the colon is abnormally distended, and may in severe or untreated cases lead to colonic [[perforation]], sepsis, and death.<ref name="Desai Elnaggar Hanfy Doshi 2020 pp. 203–210">{{cite journal | last1=Desai | first1=Jiten | last2=Elnaggar | first2=Mohamed | last3=Hanfy | first3=Ahmed A. | last4=Doshi | first4=Rajkumar | title=Toxic Megacolon: Background, Pathophysiology, Management Challenges and Solutions | journal=Clinical and Experimental Gastroenterology | volume=13 | date=19 May 2020 | pmid=32547151 | pmc=7245441 | doi=10.2147/CEG.S200760 | pages=203–210 | doi-access=free }}</ref>