What is the management of ulcerative colitis?

Management of Ulcerative Colitis

The management of ulcerative colitis should follow a stepwise approach based on disease severity, extent, and pattern, with aminosalicylates as first-line therapy for mild-to-moderate disease and biologics for moderate-to-severe disease. 1

Disease Assessment

Before initiating treatment, it's essential to:

• Classify disease extent: proctitis, left-sided, or extensive (pancolitis)
• Determine disease severity: mild, moderate, or severe
• Evaluate for extraintestinal manifestations
• Rule out infectious causes (especially C. difficile)

The Truelove and Witts criteria can identify severe UC: bloody stool frequency ≥6/day plus at least one of: tachycardia >90/min, temperature >37.8°C, hemoglobin <10.5 g/dl, or ESR >30 mm/h (or CRP >30 mg/l) 1

Treatment Algorithm by Disease Extent and Severity

1. Ulcerative Proctitis (Limited to Rectum)

• First-line: Mesalamine 1g suppository once daily 1
  • Alternative: Mesalamine foam or enemas (suppositories deliver drug more effectively to rectum)
  • Topical mesalamine is more effective than topical steroids
• For inadequate response: Combine topical mesalamine with oral mesalamine or topical steroids 1
• For refractory proctitis: Consider systemic steroids, immunosuppressants, and/or biologics 1

2. Left-sided UC (Up to Splenic Flexure)

• First-line: Combination of aminosalicylate enema ≥1 g/day PLUS oral mesalamine ≥2.4 g/day 1
  • Once-daily dosing with mesalamine is as effective as divided doses
  • Topical mesalamine is more effective than topical steroids
• For inadequate response (symptoms persisting beyond 10-14 days or no sustained relief after 40 days):
  • Add oral corticosteroids (prednisolone 40 mg daily) 1
  • Budesonide MMX 9 mg/day can be considered for patients with mild-moderate disease inadequately controlled with 5-ASA 1

3. Extensive UC (Beyond Splenic Flexure)

• Mild-to-moderate disease:
  • Aminosalicylate enema 1 g/day PLUS oral mesalamine ≥2.4 g/day 1
  • High-dose mesalamine (4.8 g/day) may be more effective for moderate disease 1
• Moderate-to-severe disease:
  • Systemic corticosteroids (prednisolone 40 mg daily) 1
  • For high-risk patients: Early use of biologics (infliximab or vedolizumab preferred) with or without immunomodulators 1

4. Severe UC (Requiring Hospitalization)

• Immediate management:
  • IV methylprednisolone 40-60 mg/day or equivalent 1
  • Daily physical examination, vital signs monitoring, stool chart
  • Regular lab monitoring (CBC, CRP, electrolytes, albumin, liver function)
  • Daily abdominal radiography if colonic dilatation present
  • IV fluids, electrolyte replacement, blood transfusion if needed
  • Subcutaneous heparin for thromboembolism prophylaxis 1
• For steroid-refractory disease (no response after 3-5 days):
  • Infliximab (5 mg/kg at 0,2, and 6 weeks, then every 8 weeks) 1, 2 or
  • Cyclosporine 1
• Consider surgery if no response to medical therapy or complications develop

Maintenance Therapy

• All patients should receive maintenance therapy to reduce relapse risk 1
• First-line maintenance: Aminosalicylates (oral mesalamine ≥2.4 g/day) 1
• For patients requiring biologics for induction: Continue biologics for maintenance 1
• For frequent relapsers or steroid-dependent disease: Consider immunomodulators (azathioprine, mercaptopurine) or biologics 1
• Duration: Lifelong maintenance therapy is generally recommended, especially for left-sided or extensive disease 1

Emerging Therapies

• Probiotics: Some evidence for VSL#3 when added to standard therapy 1
• Fecal microbiota transplantation: Emerging evidence shows potential benefit 1
• Small molecule inhibitors: Tofacitinib and ozanimod for moderate-to-severe disease 3

Important Considerations

• Medication adherence: Once-daily dosing of mesalamine improves compliance 1
• Cancer surveillance: Begin colonoscopy screening 8 years after diagnosis 3
• Combination therapy: Biologic agents with immunomodulators are more effective than monotherapy but carry increased side effect risk 1
• Medication discontinuation: Patients in remission with biologics/immunomodulators after prior 5-ASA failure may discontinue 5-ASA 1

Common Pitfalls to Avoid

1. Delaying treatment escalation: If no improvement with 5-ASA after 10-14 days for rectal bleeding or 40 days for complete symptom resolution, escalate therapy 1
2. Inadequate dosing: Using insufficient doses of 5-ASA (should be ≥2.4 g/day) 1
3. Overlooking topical therapy: Combined oral and topical therapy is more effective than either alone 1
4. Failing to assess disease severity accurately: Severe disease requires hospitalization and intensive management 1
5. Not monitoring for complications: Regular assessment for extraintestinal manifestations, dysplasia, and colorectal cancer is essential 3

Despite advances in medical therapies, approximately 7% of patients will require colectomy within 5 years of diagnosis, and the risk of colorectal cancer after 20 years of disease duration is 4.5% 3. Close monitoring and timely treatment adjustments are critical for optimizing outcomes and quality of life.