What is the next best step in managing a patient with severe ulcerative colitis flare who is not responding to initial treatment?

From the Guidelines

For a patient with severe ulcerative colitis (UC) flare not responding to initial treatment, the next best step is to escalate to intravenous corticosteroids, typically methylprednisolone 40-60mg daily, as the current dose of 20mg every eight hours may not be sufficient, and closely monitor clinical response. The patient's current symptoms, including eight bowel movements within the past 24 hours, abdominal pain, and decreased appetite, along with laboratory studies showing a low hemoglobin level of 8.1 g/dL, an elevated leukocyte count of 13,000/uL, and a serum lactate level of 1.8 mmol/L, indicate a severe UC flare that requires aggressive management.

Given the patient's lack of response to initial treatment, it is essential to consider rescue therapy options, such as infliximab or cyclosporine, as recommended by the AGA clinical practice guidelines on the management of moderate to severe ulcerative colitis 1. The guidelines suggest that infliximab and vedolizumab may be preferred first-line therapy in biologic-naïve patients, while cyclosporine may be considered for patients with prior exposure to infliximab.

The patient's clinical presentation and laboratory results should be closely monitored, and surgical consultation should be obtained early in the course for steroid-refractory patients, as colectomy may be necessary if medical therapy fails 1. Concurrent management should include bowel rest, fluid and electrolyte replacement, DVT prophylaxis, and stool testing to rule out infections like C. difficile.

Key considerations in managing this patient include:

• Escalating intravenous corticosteroids to a sufficient dose, such as methylprednisolone 40-60mg daily
• Considering rescue therapy options, such as infliximab or cyclosporine, if there is no improvement within 72 hours
• Obtaining surgical consultation early in the course for steroid-refractory patients
• Providing concurrent management, including bowel rest, fluid and electrolyte replacement, DVT prophylaxis, and stool testing to rule out infections like C. difficile.

By taking an aggressive approach to managing this patient's severe UC flare, it is possible to prevent life-threatening complications, such as toxic megacolon and perforation, and improve morbidity, mortality, and quality of life outcomes 1.

From the FDA Drug Label

1. 3 Ulcerative Colitis AVSOLA 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 (UC) who have had an inadequate response to conventional therapy. The next best step in managing a patient with severe ulcerative colitis flare who is not responding to initial treatment is to consider biologic therapy, such as infliximab 2, as the patient has had an inadequate response to conventional therapy. Key points to consider:

• The patient's symptoms, such as bloody diarrhea and crampy abdominal pain, suggest a severe ulcerative colitis flare.
• The patient has not responded to initial treatment with intravenous methy|prednisolone and hydromorphone.
• 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

Patient Assessment

The patient is a 40-year-old woman with a history of ulcerative colitis, currently experiencing a severe flare characterized by bloody diarrhea, crampy abdominal pain, and diffuse wall-thickening of the colon. Despite initial treatment with intravenous methyprednisolone and hydromorphone, she continues to have frequent bowel movements, abdominal pain, and decreased appetite.

Laboratory and Clinical Findings

• Hemoglobin: 8.1 g/dL, indicating anemia
• Leukocyte count: 13,000/uL, suggesting an inflammatory response
• Serum lactate: 1.8 mmol/L, within normal limits
• Basic metabolic panel: Normal
• Flexible sigmoidoscopy findings consistent with ulcerative colitis

Management Considerations

Given the patient's lack of response to initial corticosteroid treatment, consideration of rescue therapies is necessary. Options include:

• Cyclosporine: Effective in acute steroid-refractory ulcerative colitis, as shown in studies 3, and can be used at low doses to avoid high-dose steroids.
• Infliximab: A viable option for patients with severe ulcerative colitis who do not respond to steroids, with evidence supporting its use in steroid-refractory cases 4, 5.

Potential Next Steps

• Cyclosporine or Infliximab Therapy: Initiating either cyclosporine or infliximab as a rescue therapy could be considered based on the patient's clinical condition and response to previous treatments.
• Surgical Evaluation: If medical therapy fails, surgical intervention may be necessary. However, studies suggest that rescue therapy with cyclosporine or infliximab does not increase the risk of postoperative complications 6.
• Close Monitoring: The patient should be closely monitored for signs of worsening disease, such as increased abdominal pain, fever, or significant changes in bowel habits, which may necessitate urgent surgical evaluation.

Key Considerations

• The decision to proceed with either cyclosporine or infliximab should be based on the patient's specific clinical scenario, including the severity of disease, previous response to therapies, and potential side effects of the medications.
• The patient's anemia and inflammatory response should be addressed concurrently with the management of the ulcerative colitis flare.