From the Guidelines
For a UC flare-up, immediate hospitalization is necessary if symptoms include severe pain, high fever, significant bleeding, or inability to keep food down, as indicated by the modified Truelove and Witts criteria 1. Initial management typically includes increasing current medications, such as adding rectal mesalamine or increasing oral mesalamine to 4.8g daily for more extensive disease. Corticosteroids, like prednisone 40mg daily for 1-2 weeks, are often needed for moderate to severe flares, with a gradual taper over 8-12 weeks 1. Biologics, such as infliximab or vedolizumab, may be considered for severe flares not responding to steroids 1. It is essential to stay hydrated, follow a low-residue diet temporarily, and avoid NSAIDs and antibiotics, which can worsen symptoms. Colonoscopy is the modality of choice to assess disease activity, but in cases of acute severe UC, flexible sigmoidoscopy should be considered 1. Prompt treatment is crucial, as prolonged inflammation increases the risk of complications and colon damage. Key considerations in managing UC flare-ups include:
- Increasing current medications, such as mesalamine
- Using corticosteroids for moderate to severe flares
- Considering biologics for severe flares not responding to steroids
- Staying hydrated and following a low-residue diet
- Avoiding NSAIDs and antibiotics
- Undergoing colonoscopy or flexible sigmoidoscopy to assess disease activity, as recommended by the ECCO-ESGAR guideline 1.
From the FDA Drug Label
The proportion of patients who maintained remission at Month 6 in this study using mesalamine 2. 4 g once daily (84%) was similar to the comparator (82%). Of the 26 patients in the recommended mesalamine dosage arm, 65% achieved the primary endpoint after 8 weeks of treatment Of the 42 patients in the recommended mesalamine dosage arm, 55% achieved the primary endpoint, which was defined the same as in the 8-week phase. Of the 42 patients in the recommended mesalamine dosage arm, 36% achieved clinical remission.
Procedure for UC flare-up:
- The FDA drug label does not provide a specific procedure for a UC flare-up. However, the information provided suggests that mesalamine can be effective in maintaining remission and achieving clinical improvement in patients with mildly to moderately active ulcerative colitis.
- The recommended dosage of mesalamine is 2.4 g once daily 2.
- It is essential to note that the management of UC flare-ups should be individualized and guided by a healthcare provider.
- Patients should be advised to complete all blood tests ordered by their healthcare provider and to inform their healthcare provider if they experience any signs of renal impairment 2.
From the Research
Procedures for UC Flare-up
To manage a UC flare-up, the following procedures can be considered:
- For mild-to-moderate UC, treatment with aminosalicylates, mesalamine, and topical corticosteroids can be effective 3, 4, 5
- Oral corticosteroids can be reserved for unresponsive cases of mild-to-moderate UC 3
- For moderate-to-severe UC, oral or intravenous corticosteroids may be necessary in the short-term, with consideration of long-term management options such as biologic agents or thiopurines 3
- Patients with severe or fulminant UC who are recalcitrant to medical therapy or develop disease complications may require colectomy 3
Treatment Options
The following treatment options can be considered for UC flare-ups:
- Mesalamine with Multi-Matrix System (MMX) technology, an oral once-daily tablet formulation, can be effective in inducing and maintaining clinical remission in patients with mild-to-moderate UC 4
- Topical mesalazine (suppositories or enemas) can be effective in maintenance treatment and for patients with distal UC 6, 5
- Azathioprine and mercaptopurine can be effective in reducing the need for corticosteroids or clinical relapses in patients with chronically active or corticosteroid-dependent disease 6
- Cyclosporin may be useful in inducing remission in patients with acutely severe disease who do not achieve remission with an intensive intravenous regimen 6
Maintenance Therapy
Maintenance therapy is crucial to prevent UC flare-ups:
- Oral 5-ASA is safe and effective in maintenance treatment and can reduce the risk of colorectal tumors in patients with longstanding UC 5
- Topical mesalazine (suppositories or enemas) can also be effective in maintenance treatment 6, 5
- However, there is limited use of maintenance therapy in routine clinical practice, and few patients receive maintenance therapy 7