What is the recommended intravenous (IV) treatment for severe colitis?

Intravenous Treatment for Severe Colitis

The recommended first-line intravenous treatment for severe colitis is intravenous corticosteroids, specifically methylprednisolone 60 mg daily or hydrocortisone 100 mg four times daily, with rescue therapy using either infliximab or cyclosporine for steroid-refractory cases. 1

Initial IV Treatment for Severe Colitis

First-Line Therapy

• IV Corticosteroids:
  • Methylprednisolone 60 mg/day OR
  • Hydrocortisone 100 mg four times daily 1
  • Treatment duration: 7-10 days (extending beyond this period offers no additional benefit) 1
  • Higher doses have not shown greater efficacy 1

Supportive Measures (to be initiated concurrently)

• IV fluid and electrolyte replacement (potassium supplementation of at least 60 mmol/day) 1
• Subcutaneous low-molecular-weight heparin for thromboembolism prophylaxis 1
• Nutritional support if malnourished (enteral nutrition preferred over parenteral) 1
• Blood transfusion to maintain hemoglobin above 8-10 g/dl 1

Assessment of Response to IV Corticosteroids

Day 3 Assessment (Critical Decision Point)

• Poor response indicators:

  • 8 stools per day OR

  • 3-8 stools per day with CRP >45 mg/L 1

Day 7 Assessment

• Poor response indicators:

  • 3 stools per day OR

  • Visible blood in stool 1

Rescue Therapy for Steroid-Refractory Cases

If no adequate response to IV corticosteroids by day 3-5, initiate rescue therapy:

Option 1: Infliximab

• Dosing: 5 mg/kg IV at weeks 0,2, and 6, followed by maintenance every 8 weeks 1, 2
• Advantages:
  • Better maintenance option for long-term therapy
  • Preferred in patients previously exposed to immunosuppressives 3

Option 2: Cyclosporine

• Dosing: 2 mg/kg/day IV 1, 3
• Advantages:
  • Rapid onset of action
  • Short half-life (beneficial in patients with imminent risk of colectomy) 3
  • Can be used as monotherapy in patients who should avoid steroids 1

Diagnostic Workup During Treatment

• Unprepared flexible sigmoidoscopy and biopsy to confirm diagnosis and exclude cytomegalovirus infection 1
• Stool cultures and C. difficile toxin assay 1
• Daily monitoring of vital signs, stool frequency, and laboratory parameters 4
• Daily abdominal radiography if colonic dilatation is present (transverse colon diameter >5.5 cm) 4

Common Pitfalls to Avoid

1. Delayed recognition of steroid failure: Assess response by day 3 and promptly initiate rescue therapy if needed 1, 4
2. Prolonged IV steroid use: Extending beyond 7-10 days offers no additional benefit 1
3. Inappropriate use of antibiotics: Routine adjunctive antibiotics are not recommended unless specific infection is suspected 1
4. Delayed surgical consultation: Early multidisciplinary approach between gastroenterologists and colorectal surgeons is essential 1, 4
5. Inadequate thromboprophylaxis: Hospitalized colitis patients have significantly increased VTE risk 1

Surgical Considerations

Consider colectomy in patients with:

• Failure to respond to medical therapy within 48-72 hours
• Toxic megacolon with clinical deterioration
• Free perforation or life-threatening hemorrhage 4

The evidence strongly supports early decisive action with IV corticosteroids followed by timely assessment of response and appropriate escalation to rescue therapy when needed, rather than prolonged ineffective steroid treatment.