What is the treatment for an ulcerative colitis flare?

Treatment of Ulcerative Colitis Flare

The treatment of ulcerative colitis flare should begin with oral aminosalicylates (5-ASA) combined with topical therapy based on disease location, with systemic corticosteroids reserved for moderate to severe disease or those who fail to respond to initial therapy. 1

Treatment Algorithm Based on Disease Extent and Severity

Proctitis (Disease Limited to Rectum)

• First-line therapy: Mesalamine 1g suppository once daily 1
  • Alternative: Mesalamine foam or enemas (though suppositories deliver medication more effectively to the rectum) 1
• If inadequate response: Add oral mesalamine 2-4g/day 1
• For refractory proctitis: Oral prednisolone 40mg daily with gradual taper over 8 weeks 1

Left-Sided Colitis (Up to Splenic Flexure)

• First-line therapy: Combination of:
  • Topical mesalamine enemas (1g/day) AND
  • Oral mesalamine ≥2.4g/day (once-daily dosing is as effective as divided doses) 1
• If inadequate response: Oral prednisolone 40mg daily with gradual taper over 8 weeks 1

Extensive Colitis (Beyond Splenic Flexure)

• Mild to moderate disease:
  • Oral mesalamine ≥2.4g/day (up to 4.8g/day) 1
  • Consider adding mesalamine enemas for additional benefit 1
• Moderate to severe disease:
  • Oral prednisolone 40mg daily with gradual taper over 6-8 weeks 1
  • Single daily dosing is as effective as split-dosing and causes less adrenal suppression 1

Severe Ulcerative Colitis (Requiring Hospitalization)

• Criteria for hospitalization: Bloody stool frequency ≥6/day plus at least one of:
  • Tachycardia >90 beats/min
  • Temperature >37.8°C
  • Anemia (hemoglobin <10.5 g/dl)
  • ESR >30 mm/h or CRP >30 mg/l 1
• Treatment approach:
  • Intravenous corticosteroids (hydrocortisone 400mg/day or methylprednisolone 60mg/day) 1
  • Daily physical examination, vital signs monitoring, stool charting
  • Regular laboratory monitoring (CBC, CRP, electrolytes, albumin)
  • Abdominal radiography to monitor for toxic megacolon
  • IV fluid and electrolyte replacement
  • Subcutaneous heparin for thromboembolism prophylaxis
  • Nutritional support if malnourished 1
  • Joint management with colorectal surgeon 1

Treatment Escalation for Refractory Disease

For patients who fail to respond to initial therapy or become steroid-dependent/refractory:

• Treatment escalation options:
  • Thiopurines (azathioprine, mercaptopurine) 1
  • Anti-TNF therapy (infliximab, adalimumab) 1, 2, 3
  • Vedolizumab 1
  • Tofacitinib 1

Important Clinical Considerations

• Dosing strategy: Start with adequate doses rather than under-dosing and escalating later 4
• Topical therapy effectiveness: Topical mesalamine is more effective than topical steroids 1
• Combination therapy: Combining topical and oral mesalamine is more effective than either alone 1
• Steroid tapering: Prednisolone should be tapered gradually over 6-8 weeks to minimize risk of early relapse 1
• Maintenance therapy: After achieving remission, patients should continue maintenance therapy to prevent relapse 1

Potential Pitfalls and Caveats

1. Delayed escalation: Prolonging treatment with high-dose oral corticosteroids has diminishing chances of achieving remission and increases risk of steroid dependence 1

2. Infection risk: Always rule out infectious causes (especially C. difficile) before intensifying immunosuppression 2, 3

3. Malignancy risk: Long-term immunosuppression, especially combination therapy with anti-TNF agents and thiopurines, increases risk of certain malignancies, particularly hepatosplenic T-cell lymphoma in young males 2, 3

4. Monitoring requirements: Regular assessment of disease activity using both clinical symptoms and objective markers (fecal calprotectin, CRP) helps guide therapy adjustments 5

5. Proximal constipation: Can exacerbate distal disease and should be treated with stool bulking agents or laxatives 1