TREATMENT What Are the Differences in Treatment of Ulcerative Colitis Between Pediatric and Adult Patients? Salvatore Cucchiara, MD M anagement of ulcerative colitis (UC) in childhood is largely the same as in adulthood. Drugs constitute the mainstay of treatment of children and adolescents with UC; however, most controlled studies have been conducted in adults and indications for pharmacologic intervention in chil- dren have been extrapolated from these studies. Indeed, there are few randomized, double-blind, placebo-controlled clinical trials in children with inflammatory bowel disease (IBD). The challenge in treating each child or adolescent with IBD is to use pharmacologic, nutritional, and surgical therapies in order to reduce intestinal inflammation and to improve growth pattern, thereby optimizing quality of life and normal social development. 1 Growth retardation is a major problem in children with IBD, as they have smaller nutritional reserves and higher nutritional requirements than adults. In children with IBD the growth pattern is influenced both by the inflam- matory process per se and a chronic use of drugs such as corticosteroids (CS). Optimal care of pediatric patients with UC must always include consideration of bioumoral nutri- tional variables as well as regular monitoring of height ve- locity and pubertal development. In disease of mild degree and short duration, growth failure appears as reduced weight for height; on the other hand, in long-standing disease linear growth can be significantly affected. Assessing growth is a variable for measuring the success of therapy. 2 In children with mild-to-moderate UC, the aminosa- licylates sulfasalazine and 5-aminosalicylic acid (5-ASA, me- salamine or mesalazine) are the first-line drugs with modest antiinflammatory effect. Sulfasalazine is started at 25– 40 mg/kg/day, to arrive at 75 mg/kg/day, but the effective dose of mesalazine has not clearly been reported: however, an initial dose of 50 mg/kg/day is currently suggested. There is no compelling evidence for a therapeutic advantage of one oral 5-ASA over the others. Both sulfasalazine and 5-ASA are effective in maintaining clinical remission, reducing the 60%–70% natural annual relapse to 30%. However, children seem to tolerate mesalazine better than sulfasalazine; symp- toms such as nausea, vomiting, rash, headache, and pruritis occur more frequently during treatment with sulfasalazine than with mesalazine. 3 Corticosteroids are the mainstay agents for moderate or severe acute attacks of UC. A routine practice is to give daily prednisone (1 mg/kg/day, maximum 40 – 60 mg) for 3– 6 weeks, depending on the severity of episodes and the rapidity of response, and then to gradually discontinue treatment by reducing the dose at weekly intervals. Sulfasalazine or oral 5-ASA are usually given in combination with CS as a therapy for moderate to severe UC: one advantage from this strategy is that the child will already be on aminosalicylates when the CS will be stopped. A precocious introduction of immuno- modulators such as azathioprine (AZA, begun at 1.0 mg/kg/ day to arrive at 2.0 –2.5 mg/kg/day) or 6-mercaptopurine (6-MP, 1.5 mg/kg/day) or methotrexate (15 mg/m 2 , subcuta- neously on a weekly basis) in association with CS is a widely agreed approach, being the immunomodulators of value in the long-term maintenance of remission; furthermore, a ste- roid-sparing effect has been demonstrated in 70 –75% of children receiving AZA on a long-term basis. Immunomodu- lators are considered safe and effective, even though the possibility of malignancy is worrisome in children, as they have potential for long-term exposure. However, side effects related to high and/or prolonged of CS treatment are so important in childhood that the use of immunomodulators as steroid-sparing drugs should always to be considered. 4 Severe fulminating cases of UC usually necessitate hospitalization because of an intrinsic risk of mortality and colectomy and are traditionally treated with intravenous high doses of CS that can promote a remission rate of 60%–75%. Patients failing to respond will receive cyclosporine. The latter, an immunosuppressive agent that was originally devel- oped to prevent organ rejection following transplantation, is used intravenously (2 mg/kg/day) and may prevent short-term colectomy in more than two-thirds of subjects. However, it seems that after a follow-up period of 18 months, only 45% of patients avoided colectomy, despite the use of AZA or 6-MP. 5 Administration of cyclosporine includes careful sur- veillance for infections and renal function, due to the well- known toxicity of the drug. The use of cyclosporine as a bridge to maintenance therapy with safer immunomodulators such as AZA or 6-MP may represent a strategy useful for a sustained remission. Nevertheless, the potential risks of a short-term triple immunosuppression (CS, cyclosporine, and From the Pediatric Gastroenterology & Liver Unit, Sapienza University of Rome, Rome, Italy. Copyright © 2008 Crohn’s & Colitis Foundation of America, Inc. DOI 10.1002/ibd.20725 Published online in Wiley InterScience (www.interscience.wiley.com). S224 Inflamm Bowel Dis ● Volume 14, Number S2, A Clinician’s Guide to IBD