What is the acute treatment of ulcerative colitis (UC)?

From the Guidelines

The acute treatment of ulcerative colitis should involve intravenous methylprednisolone at a dose equivalent of 40 to 60mg/d, as this has been shown to decrease the risk of colectomy in hospitalized adults with acute severe ulcerative colitis. This approach is based on the most recent and highest quality evidence available, specifically the 2020 AGA clinical practice guidelines on the management of moderate to severe ulcerative colitis 1.

When managing hospitalized patients with acute severe ulcerative colitis, it is essential to consider the following key points:

• Intravenous corticosteroids are the mainstay of treatment, with doses equivalent to 40–60mg/day of methylprednisolone being recommended 1
• The use of higher doses of intravenous corticosteroids has not been shown to be more effective, and may increase the risk of adverse events 1
• Treatment should be given for a defined period, typically 3-5 days, as extending therapy beyond 7-10 days carries no additional benefit 1
• Patients should receive adequate volume of intravenous fluids, and low-molecular-weight heparin for thromboprophylaxis, and electrolyte abnormalities and anemia should be corrected if needed 1

In cases where patients do not respond to intravenous steroids within 3-5 days, rescue therapy with infliximab or cyclosporine should be considered 1. Additionally, colectomy may be necessary for patients with toxic megacolon, perforation, or those failing medical therapy. Throughout treatment, patients should avoid NSAIDs and high-fiber foods, maintain hydration, and be monitored for complications like anemia and infection. This approach targets the underlying inflammatory process while supporting the patient through the acute phase of illness.

From the FDA Drug Label

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.

For induction of remission: 2.4 g to 4.8 g (two to four 1.2-g tablets) once daily.

For maintenance of remission: 2.4 g (two 1. 2-g tablets) once daily.

The acute treatment of ulcerative colitis can be managed with:

• Infliximab (IV): 5 mg/kg given as an intravenous induction regimen at 0,2 and 6 weeks 2
• Mesalamine (PO): 2.4 g to 4.8 g (two to four 1.2-g tablets) once daily for induction of remission 3

From the Research

Acute Treatment of Ulcerative Colitis

• The management of acute severe ulcerative colitis (ASUC) requires a multidisciplinary team approach in a specialized center or with expert consultation 4, 5.
• Intravenous corticosteroids are the cornerstone of treatment for ASUC and should be initiated promptly, along with general management measures and close monitoring of patients 4, 5.
• Response to intravenous corticosteroid therapy should be assessed on the third day, and rescue therapies such as cyclosporine and infliximab should be offered to patients who do not respond 4, 5.
• The choice of rescue therapy depends on factors such as experience, drug availability, and individual patient characteristics, including comorbidities and previous medications 4.

Rescue Therapies and Surgery

• Patients who do not respond to rescue therapy within 7 days should be considered for surgery 4, 5.
• Surgery is a treatment option for ASUC and should not be delayed in cases of failure of medical therapy, as delays can increase surgical morbidity and mortality 4, 5.
• Subtotal colectomy with ileostomy and preservation of the rectum is a potential treatment option for patients with ASUC who require surgery 5.

Medical Management

• Mesalamine is a first-line therapy for inducing and maintaining clinical remission in patients with mild-to-moderate ulcerative colitis 6.
• For patients who are refractory to mesalamine or have more severe disease, steroids, azathioprine/mercaptopurine, cyclosporine, or infliximab may be used to induce and/or maintain remission 6.
• Intravenous corticosteroids can be effective for inducing remission in moderately active ulcerative colitis that is unresponsive to oral corticosteroids, but may be associated with steroid-dependency in some patients 7.