What is the best initial treatment approach for an acute ulcerative colitis flare-up?

From the Guidelines

The best initial treatment approach for an acute ulcerative colitis flare-up is oral 5-aminosalicylic acid (5-ASA) medications, such as mesalamine, at doses of 2-3 g daily, as recommended by the British Society of Gastroenterology consensus guidelines 1. For patients with mild to moderate ulcerative colitis, oral 5-ASA is the first-line treatment, with the option to add 5-ASA enemas for those with distal disease.

• The guidelines suggest that patients who fail to respond to 5-ASA therapy should receive dose escalation to 4-4.8 g/day orally, alongside 5-ASA enemas 1.
• For patients with moderate to severe flares, oral corticosteroids like prednisone at 40-60mg daily with a gradual taper over 8-12 weeks are typically added, as supported by the third European evidence-based consensus on diagnosis and management of ulcerative colitis 1.
• Hospitalization may be necessary for intravenous steroids (methylprednisolone 40-60mg daily) and close monitoring if symptoms include severe pain, bloody diarrhea, fever, or tachycardia, as recommended by the review article on acute severe ulcerative colitis 1.
• Treatment should be adjusted based on disease severity, extent of colonic involvement, and response to therapy, with escalation to biologics like infliximab or vedolizumab if there is inadequate response to initial therapy within 3-5 days of intravenous steroids, as suggested by the clinical practice guidelines for the medical management of nonhospitalized ulcerative colitis 1. Key considerations in managing acute ulcerative colitis flare-ups include:
• Hydration, electrolyte replacement, and nutritional support as important supportive measures.
• Close monitoring of patients, especially those with severe symptoms, to determine the need for hospitalization or escalation of therapy.
• The use of topically-acting oral corticosteroids, such as budesonide MMX, as an alternative to systemic corticosteroids for patients with mild to moderate ulcerative colitis who wish to avoid systemic steroids 1.

From the FDA Drug Label

HIGHLIGHTS OF PRESCRIBING INFORMATION These highlights do not include all the information needed to use RENFLEXIS safely and effectively. See full prescribing information for RENFLEXIS. RENFLEXIS (infliximab-abda) for injection, for intravenous use Initial U. S. Approval: 2017 RENFLEXIS (infliximab-abda) is biosimilar* to REMICADE (infliximab). (1) Ulcerative Colitis: • reducing signs and symptoms, inducing and maintaining clinical remission and mucosal healing, and eliminating corticosteroid use in adult patients with moderately to severely active disease who have had an inadequate response to conventional therapy. (1. 3)

The recommended dosage of RENFLEXIS is 5 mg/kg at 0,2 and 6 weeks, then every 8 weeks. (2.3)

The best initial treatment approach for an acute ulcerative colitis flare-up is not explicitly stated in the provided drug labels. However, based on the available information, infliximab (IV) 2 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. The recommended dosage is 5 mg/kg at 0,2, and 6 weeks, then every 8 weeks.

• Key points:
  • Infliximab is used for moderately to severely active ulcerative colitis.
  • The recommended dosage is 5 mg/kg at 0,2, and 6 weeks, then every 8 weeks.
  • Infliximab can help reduce signs and symptoms, induce and maintain clinical remission, and promote mucosal healing.

From the Research

Treatment Approaches for Acute Ulcerative Colitis Flare-up

The best initial treatment approach for an acute ulcerative colitis flare-up depends on the severity of the disease.

• For mild-to-moderate ulcerative colitis, treatment options include:
  • Aminosalicylates, such as mesalamine 3
  • Topical corticosteroids 3
  • Oral corticosteroids for unresponsive cases 3
• For moderate-to-severe ulcerative colitis, treatment options include:
  • Oral or intravenous corticosteroids in the short-term 3, 4
  • Biologic agents, such as infliximab, as initial therapy or in transition from steroids 3, 4
  • Thiopurines, such as azathioprine, as bridging therapy 3, 5
• For severe or fulminant ulcerative colitis, treatment options include:
  • Intravenous corticosteroids as first-line therapy 4, 6
  • Calcineurin inhibitors, such as cyclosporine or tacrolimus, for patients who do not respond to corticosteroids 4, 6
  • Colectomy for patients who are recalcitrant to medical therapy or who develop disease complications 3, 6, 5

Importance of Early Assessment and Treatment

Early assessment and treatment of acute ulcerative colitis are crucial to prevent complications and improve outcomes.

• Clinical and endoscopic assessment of disease severity is essential to determine the best treatment approach 6
• Risk stratification and the use of predictive clinical parameters can help identify patients who are at high risk of complications and require aggressive treatment 4
• Multidisciplinary teams, including inflammatory bowel disease experts, colorectal surgeons, and other medical staff, can contribute to better management of patients with acute severe ulcerative colitis 4