What is the initial treatment for a flare of ulcerative colitis?

From the Guidelines

The initial treatment for a flare of ulcerative colitis should involve oral 5-aminosalicylic acid (5-ASA) 2–3 g/day, with the addition of 5-ASA enemas for optimal management. This approach is supported by the most recent and highest quality evidence, including the British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults 1.

Key Considerations

• For mild to moderate flares, 5-ASA medications such as mesalamine, administered orally at doses of 2.4-4.8g daily or rectally as suppositories (1g daily) or enemas (2-4g daily) for distal disease, can be effective within 2-4 weeks.
• If symptoms are more severe or don't respond to 5-ASA therapy, oral corticosteroids like prednisone at 40-60mg daily with a gradual taper over 8-12 weeks are often necessary.
• For patients with limited distal disease, topical corticosteroids such as hydrocortisone enemas or foam may be sufficient.
• During flares, patients should maintain adequate hydration, consider a low-residue diet to reduce bowel irritation, and avoid NSAIDs which can worsen symptoms.

Evidence-Based Recommendations

• The use of 5-ASA as the first-line treatment is based on high-quality evidence from recent studies, including those published in 2019 1 and 2020 1, which emphasize the importance of early and effective treatment to prevent disease progression.
• The addition of 5-ASA enemas to oral 5-ASA therapy is recommended for optimal management, as stated in the guidelines 1.
• For patients who do not respond to 5-ASA therapy or have more severe symptoms, the use of oral corticosteroids or biologic agents may be necessary, as suggested by the AGA clinical practice guidelines on the management of moderate to severe ulcerative colitis 1.

Patient Care

• Prompt treatment is essential to prevent progression to more severe disease requiring hospitalization or surgical intervention.
• Patients should be closely monitored for response to treatment and adjusted as necessary to achieve and maintain remission.
• Education on disease management, including diet, hydration, and avoidance of NSAIDs, is crucial for optimal patient outcomes.

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. 8 g/day The initial treatment for a flare of ulcerative colitis may include mesalamine at a dose of 8 g/day or infliximab (RENFLEXIS) at a dose of 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 2.

• Key considerations for treatment include:
  • Dose and administration: The dose and administration of the medication should be carefully considered, with mesalamine typically given orally and infliximab (RENFLEXIS) given intravenously.
  • Treatment goals: The goal of treatment is to reduce signs and symptoms, induce and maintain clinical remission, and eliminate corticosteroid use in adult patients with moderately to severely active ulcerative colitis.
  • Patient monitoring: Patients should be closely monitored for the development of signs and symptoms of infection during and after treatment with infliximab (RENFLEXIS) 2.

From the Research

Treatment for a Flare of Ulcerative Colitis

The initial treatment for a flare of ulcerative colitis depends on the severity of the disease.

• For mild-to-moderate ulcerative colitis, treatment options include:
  • Aminosalicylates, such as mesalamine 3, 4, 5, 6
  • Topical corticosteroids 3, 5
  • Oral corticosteroids for unresponsive cases 3
• For moderate-to-severe ulcerative colitis, treatment options include:
  • Oral or intravenous corticosteroids in the short-term 3
  • Biologic agents, such as golimumab, as initial therapy or in transition from steroids 3, 7
  • Thiopurines as bridging therapy 3
• For severe or fulminant ulcerative colitis, treatment options include:
  • Colectomy, which may be a life-saving procedure 3

Disease Severity and Treatment

Disease severity is a crucial factor in determining the treatment approach for ulcerative colitis.

• Mild disease can often be managed with aminosalicylates and topical corticosteroids 4, 5, 6
• Moderate-to-severe disease may require more aggressive treatment, including biologic agents and thiopurines 3, 7
• Severe or fulminant disease may require colectomy or other surgical interventions 3

Treatment Goals

The primary goals of treatment for ulcerative colitis are to:

• Induce remission 3, 7, 4
• Maintain remission 3, 4, 6
• Improve quality of life 3, 7