What is the treatment for an ulcerative colitis (UC) flare-up?

From the Guidelines

Treatment for an ulcerative colitis flare-up should start with oral 5-aminosalicylates (5-ASAs) like mesalamine at doses of 2.4-4.8g daily, combined with an aminosalicylate enema 1g/day for mild to moderately active extensive ulcerative colitis, as recommended by the European evidence-based consensus on diagnosis and management of ulcerative colitis 1. For moderate to severe flares, oral corticosteroids such as prednisone at 40-60mg daily with a gradual taper over 8-12 weeks are often necessary, with a strong recommendation for their use in patients with moderate to severe active UC 1. In severe cases, hospital admission for intensive treatment with intravenous steroids, such as methylprednisolone 60 mg each 24 h or hydrocortisone 100 mg four times daily, may be required, along with adequate volume of intravenous fluids, low-molecular-weight heparin for thromboprophylaxis, and correction of electrolyte abnormalities and anaemia if needed 1. Some key points to consider in the management of ulcerative colitis flare-ups include:

• Maintaining hydration and following a low-residue diet to help control symptoms
• Avoiding spicy foods, caffeine, and alcohol, which can exacerbate symptoms
• Getting adequate rest to help the body recover from the flare-up
• Monitoring for signs of severe disease, such as severe abdominal pain, high fever, or significant bleeding, which may require hospitalization
• Considering the use of immunomodulators like azathioprine or biologics such as infliximab in severe cases, although the evidence for these treatments is not as strong as for 5-ASAs and corticosteroids 1. It's also important to note that the approach to treatment of severe UC involves joint medical and surgical management, with daily physical examination, recording of vital signs, and measurement of laboratory tests, such as FBC, ESR, or CRP, serum electrolytes, serum albumin, and liver function tests 1.

From the FDA Drug Label

1. 3 Ulcerative Colitis RENFLEXIS is indicated for reducing signs and symptoms, inducing and maintaining clinical remission and mucosal healing, and eliminating corticosteroid use in adult patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy.
2. 3 Ulcerative Colitis The recommended dose of RENFLEXIS is 5 mg/kg given as an intravenous induction regimen at 0,2 and 6 weeks followed by a maintenance regimen of 5 mg/kg every 8 weeks thereafter for the treatment of adult patients with moderately to severely active ulcerative colitis.

Treatment for Ulcerative Colitis Flare-up:

• The recommended dose of infliximab (RENFLEXIS) for adult patients with moderately to severely active ulcerative colitis is 5 mg/kg given as an intravenous induction regimen at 0,2, and 6 weeks.
• Maintenance regimen: 5 mg/kg every 8 weeks thereafter.
• Infliximab is indicated for reducing signs and symptoms, inducing and maintaining clinical remission, and mucosal healing in adult patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy 2.

From the Research

Treatment Options for Ulcerative Colitis Flareup

• The primary goal of treatment is to induce and maintain remission of symptoms and mucosal inflammation 3, 4, 5.
• Treatment options depend on the severity and extent of the inflammation, with mild-to-moderate cases often treated with topical or oral 5-aminosalicylic acid (5-ASA) 3, 4, 6.
• For patients with more severe disease, oral corticosteroids, immunosuppressive therapy with intravenous cyclosporine, or biologic therapy with infliximab may be necessary 3, 4.

Induction of Remission

• Topical treatment with 5-ASA is the treatment of choice for active distal mild-to-moderate UC 3.
• Oral aminosalicylates are effective in both distal and extensive mild-to-moderate disease, but may have lower rates of remission in distal disease compared to topical 5-ASA 3.
• New steroids, such as budesonide and beclomethasone dipropionate (BDP), administered as enemas, may be an alternative to 5-ASA therapy 3.

Maintenance of Remission

• Oral aminosalicylates are the first-line therapy for maintaining remission in UC patients 3, 5, 7.
• Topical 5-ASA may play a role in maintaining remission in patients with distal disease 3.
• Patients who are steroid dependent may be started on azathioprine or 6-mercaptopurine, although it may take up to 3 months for the treatment to become effective 3.

Severe Disease

• Patients with severe UC may require hospitalization and treatment with intravenous steroids or calcineurin inhibitors (cyclosporine, tacrolimus) 4.
• Biologic therapy with infliximab may be used in patients with severe disease who are refractory to other treatments 4.
• Indications for emergency surgery include refractory toxic megacolon, colonic perforation, or severe colorectal bleeding 4.