What is the inpatient management of an ulcerative colitis (UC) flare?

From the Guidelines

Inpatient management of ulcerative colitis (UC) flares should begin with intravenous corticosteroids, specifically methylprednisolone 40-60mg daily, for 3-5 days, as recommended by the most recent guidelines 1, 2. The management approach should prioritize reducing inflammation, preventing complications, and improving quality of life.

• Key components of inpatient management include: + Correction of fluid and electrolyte imbalances + Thromboprophylaxis with low molecular weight heparin due to increased thrombotic risk + Stool studies to rule out infectious causes, particularly C. difficile + Regular monitoring of clinical assessment, CBC, CRP, and albumin levels + Nutritional support for malnourished patients If no improvement occurs within 3-5 days of IV steroids, second-line therapy should be initiated with either infliximab or cyclosporine, as suggested by the guidelines 2, 3. Surgical consultation should be obtained early for patients with severe disease, as delayed surgery can lead to high morbidity 3. The goal of inpatient management is to transition patients to oral medications and discharge once clinical improvement occurs, typically with a tapering course of oral prednisone starting at 40-60mg daily. It is essential to note that the quality of evidence supporting these recommendations is generally considered low to very low, primarily due to the observational nature of the evidence and indirectness in approach to comparing efficacy 1. However, based on the most recent and highest quality studies available, the recommended approach prioritizes the reduction of morbidity, mortality, and improvement of quality of life for patients with ulcerative colitis flares.

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.

The inpatient management of an ulcerative colitis (UC) flare with infliximab (IV) involves administering 5 mg/kg as an intravenous induction regimen at 0, 2, and 6 weeks, followed by a maintenance regimen of 5 mg/kg every 8 weeks 4.

• Key points:
  • Dose: 5 mg/kg
  • Induction regimen: 0, 2, and 6 weeks
  • Maintenance regimen: every 8 weeks However, the provided label does not give a comprehensive view of inpatient management of UC flare.

From the Research

Inpatient Management of Ulcerative Colitis (UC) Flare

The inpatient management of an ulcerative colitis (UC) flare involves a comprehensive approach to reduce inflammation, prevent complications, and improve patient outcomes. The following are key aspects of inpatient management:

• Initial treatment strategies should take into account the current clinical presentation, extent, and severity of disease activity, as well as long-term treatment options 5.
• Mild-to-moderate UC can be managed with aminosalicylates, mesalamine, and topical corticosteroids, while oral corticosteroids are reserved for unresponsive cases 5.
• Moderate-to-severe UC generally requires oral or intravenous corticosteroids in the short-term, with consideration of long-term management options such as biologic agents or thiopurines 5.
• Inpatient management of acute severe UC typically involves intravenous corticosteroid treatment, with rescue therapy using infliximab or cyclosporine if needed 6, 7.
• Discharge criteria include resolution of rectal bleeding and return to baseline stool frequency and form, with patients often discharged on 40 mg of prednisone 8.
• Postdischarge management may involve initiation of biologic or small molecule therapy, with follow-up appointments scheduled within 2 weeks and lower endoscopy within 4-6 months 8.

Medical and Surgical Considerations

A multidisciplinary team approach, involving both gastroenterologists and surgeons, is essential for the management of hospitalized UC patients 9.

• Early surgical consultation is crucial, with consideration of colectomy as a therapeutic option for patients who are recalcitrant to medical therapy or develop disease complications 5, 9.
• Medical rescue options, such as infliximab or cyclosporine, should be considered within 3-5 days of presentation for patients who do not respond to initial corticosteroid treatment 9.
• Patient preferences and individualized treatment plans are essential for providing patient-centered effective care 9.