A 26-year-old woman with ulcerative colitis presents with abdominal pain and frequent loose stools mixed with mucus and blood. She is not on any regular medication. Which treatment should be initiated first?

• A. Loperamide
• B. Prednisolone
• C. Mesalazine
• D. Azathioprine

Answer: (C)

Starting therapy with mesalazine (5-aminosalicylic acid) is the best initial approach for a young patient presenting with active, likely mild-to-moderate ulcerative colitis. Mesalazine targets the mucosal inflammation in the colon and has a favorable safety profile, making it suitable as first-line induction therapy to reduce inflammation and induce remission. This contrasts with systemic corticosteroids, which carry more side effects and are reserved for more moderate-to-severe flares or when 5-ASA fails. Immunomodulators like azathioprine are typically used for maintenance or steroid-sparing in longer-standing or more refractory disease, not as first-line induction in a new, mild presentation. Anti-diarrheal relief with loperamide addresses symptoms only and does not treat the underlying inflammation, so it isn’t the initial treatment in active disease.