Your UC Treatment Roadmap

Written by Rachel Reiff Ellis
Medically Reviewed by Melinda Ratini, MS, DO on February 24, 2026

The goal of ulcerative colitis (UC) treatment is to ease your symptoms and keep you in that state as long as possible. For most people, this means taking one or more medications. There are many options available, and while that’s great news, it can also feel overwhelming. Which do you try first? What happens if a treatment doesn’t work? How do you know if you’re taking the option that works best?

This guide will walk you through the different options for treating your UC so you and your doctor can create a treatment plan tailored to your specific needs.

You’ll take some medication all the time to maintain your disease activity. But if you have an acute flare, you may need more or stronger medications.

Acute flares are times when your UC symptoms, such as diarrhea, bleeding, and abdominal pain, suddenly get worse. They can range from mild to severe. Severe flares can be a medical emergency and require a hospital stay. 

The goal of treating an acute flare is to reduce inflammation quickly and safely. 

Corticosteroids

Corticosteroids are medications you take either by mouth or IV infusion (for severe cases). Options include:

While corticosteroids are important for getting you out of a flare, they aren’t good options for long-term use because of their side effects, which include:

  • Acne
  • Weight gain
  • Increased appetite
  • Mood changes
  • Difficulty sleeping 

Those side effects go away when you stop using corticosteroids, but over time, you can develop other long-lasting problems, such as:

  • Osteoporosis
  • Cataracts 

Aminosalicylates (5-ASAs)

Another option for treating short-term flare is aminosalicylates (5-ASAs). These medicines are taken by mouth, as an enema, or as a suppository. Examples include:

Unlike corticosteroids, 5-ASAs are safe to take long-term, so you may also use them for maintenance treatment. Your doctor may have you take 5-ASAs in combination with corticosteroids.

Doctors have traditionally prescribed UC treatments in a “step-up” approach — starting with lower-risk, less intensive therapies before moving to advanced options (such as biologics) if symptoms don’t improve. But more recently, these guidelines are changing, depending on the extent of your disease. 

For mild UC, a step-up approach may still be the best choice. Doctors consider your UC to be mild if you have:

  • Less than four bowel movements a day
  • Some blood in your stool sometimes (not constant)
  • Low amounts of inflammation on endoscopy

With this level of UC disease activity, your doctor may suggest a 5-ASA. These are among the safest and most commonly prescribed drugs for mild to moderate UC.

If your UC is moderate to severe, doctors are shifting to a more “top-down” system that starts you on advanced treatments earlier in the process.

Doctors classify your UC as moderate to severe if you have:

  • Four to six bowel movements a day
  • Rectal bleeding with most stools
  • High amounts of inflammation on endoscopy

“With moderate to severe disease, particularly those with risk factors for more aggressive disease — younger age at diagnosis, more colon involved, need for hospitalization — starting advanced treatment as first-line is associated with better outcomes for patients, meaning fewer hospitalizations and surgeries,” says Sara Lewin, MD, gastroenterologist at UCSF Health.

Doctors often suggest this strategy for people with moderate to severe UC who have:

  • High risk of complications
  • Severe disease at diagnosis
  • Disease that’s severely affecting their quality of life

These are the broad categories of maintenance treatments for UC:

Aminosalicylates (5-ASAs)

These medications work for acute flares, but they’re safe enough to take as a maintenance drug over long periods. They’re one of the medications doctors prescribe most commonly for mild to moderate UC. 

They come as pills, but you may need to take them as a suppository or enema, depending on where the inflammation is in your colon. 

They can have some side effects, including:

  • Headache
  • Nausea
  • Abdominal pain
  • Rash
  • Diarrhea

If your UC symptoms continue or get worse after taking ASAs, your doctor may add another therapy on top of it.

Immunomodulators

These medications hold back your immune system so that inflammation goes down. They’re pills you take once a day. They can take several weeks to months to work, so doctors often start you on them along with other therapies that work more quickly, such as biologics or steroids.

Options include: 

Side effects to watch for include:

  • Higher risk of infection
  • Nausea
  • Liver enzyme changes
  • Low blood counts

Rarely, people on immunomodulators can get pancreatitis or have liver issues. In very rare cases, they can cause cancer.

Biologics

Biologic therapies are advanced medications that target specific parts of your immune system responsible for inflammation. You may get them as an infusion or as an injection under the skin.

Each kind targets a different protein. Examples include:

  • Anti-tumor necrosis factor (TNF) agents: Adalimumab and biosimilars (Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Humira, Hyrimoz, Idacio, Simlandi, Yuflyma, Yusimry); infliximab and biosimilars (Avsola, Inflectra, IXIFI, Remicade, Renflexis, Zymfentra); golimumab (Simponi)
  • Integrin receptor antagonists: Vedolizumab (Entyvio)
  • Interleukin antagonists: Guselkumab (Tremfya); mirikizumab-mrkz (Omvoh); ustekinumab (Imuldosa, Otulfi, Pyzchiva, Selarsdi, Starjemza, Stelara, Steqeyma, Wezlana, Yesintek)

Side effects can include:

  • Reaction on the skin where you get the injection or infusion
  • Increased risk of infection

Doctors often combine biologics and immunomodulators when 5-ASAs and steroids don’t work well enough.

Targeted synthetic small molecules

If you have advanced UC and you haven’t responded to anti-TNF agents, your doctor may prescribe a targeted synthetic small molecule. There are two options:

  • Janus kinase (JAK) inhibitors: Tofacitinib (Xeljanz) and upadacitinib (Rinvoq)
  • Sphingosine-1-phosphate (S1P) receptor modulators: Etrasimod (Velsipity) and ozanimod (Zeposia)

Possible side effects:

  • Increased risk of infection
  • Headaches
  • Potential blood lipid changes
  • Rarely, blood clots can happen (especially with some JAK inhibitors)

Lewin says many people have a hard time wrapping their head around starting advanced treatments right off the bat, but emphasizes that the benefit is worth it.

“I would encourage patients to be open-minded to starting advanced therapies, especially if they have risk factors for aggressive disease,” she says. “It takes a bit of a leap of faith in the beginning but ultimately will lead to clinical remission more reliably and prevent the risk of complications down the line.”

Surgery

Medications are first-line treatment for UC, but if medications can’t control your disease well enough, or you have serious complications from your UC, you may need surgery. Surgery for UC involves removing all or part of your colon (colectomy) and then either:

  • Creating a pouch inside your body (J-pouch) that works like the part of the colon your doctor removes
  • Creating a permanent hole in your stomach (stoma) and attaching a bag you wear outside your body to collect your stool

About 20%-30% with UC need surgery at some point in their life to successfully control their disease.

 

UC treatment isn’t a one-size-fits-all prescription. Discuss your treatment options with your doctor. Together, you can develop a plan that is effective, safe, and fits your needs.

“With effective and proactive treatment, many people are able to get into remission, with about 75% of people getting into remission within one year of diagnosis,” says Lewin.

Your specific treatment plan will depend on your:

  • Symptoms
  • Disease severity
  • Personal health history
  • Risk factors
  • Response to medications
  • Goals for quality of life

Lewin also suggests reaching out to others with UC as part of your fact-finding mission and as a way to build community.

“With a new diagnosis of UC, there is a lot that changes all at once,” says Lewin. “Looking for support from others who have walked this path before can be incredibly valuable.”

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