Why not use both intravenous (IV) steroids and rectal steroids for a patient with severe acute ulcerative colitis?

Management of Severe Acute Ulcerative Colitis: Why Not Use Both IV and Rectal Steroids

In severe acute ulcerative colitis, intravenous steroids alone are the recommended first-line treatment rather than combining IV and rectal steroids, as there is no evidence that combination therapy improves outcomes over IV steroids alone. 1

Standard Treatment Approach for Severe UC

First-Line Therapy

• IV corticosteroids are the established first-line treatment:
  • Methylprednisolone 60 mg daily OR
  • Hydrocortisone 100 mg four times daily 1, 2
• Higher doses are not more effective, but lower doses are less effective 1
• Treatment should be given for a defined period of 7-10 days, as extending beyond this offers no additional benefit 1, 2

Supportive Care

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

Why Rectal Steroids Are Not Added to IV Steroids

1. No Evidence of Additional Benefit: The European Crohn's and Colitis Organisation (ECCO) guidelines do not recommend the routine addition of rectal steroids to IV steroids in severe UC 1

2. Practical Limitations: In severe UC:

   • Patients often cannot retain rectal preparations due to urgency and frequency of bowel movements
   • Risk of perforation with insertion of rectal preparations in severely inflamed bowel
   • Patient discomfort and poor tolerance in the acute setting

3. Focus on Systemic Treatment: Severe UC requires immediate systemic treatment with IV steroids that can reach all affected areas of the colon 1

4. Alternative Rescue Therapies: For patients not responding to IV steroids by day 3, the focus shifts to rescue therapies such as infliximab or cyclosporine rather than adding rectal steroids 1, 2

Role of Topical Therapy in UC Management

While rectal steroids are not routinely combined with IV steroids in severe UC, topical therapy does have a role in specific scenarios:

• The ECCO guidelines mention that topical therapy (corticosteroids or 5-ASA) can be considered if tolerated and retained, but notes there have been no systematic studies in acute severe colitis 1
• Rectal corticosteroids are suggested as second-line therapy for mild to moderate active left-sided UC or proctitis that fails to respond to rectal 5-ASA therapy 1

Assessment of Treatment Response

• Response to IV steroids should be assessed by day 3 1, 2
• Poor response indicators include:

  • 8 stools per day or 3-8 stools with CRP >45 mg/L 2

  • Persistent fever, tachycardia, or elevated inflammatory markers

Rescue Therapy Options

For patients not responding to IV steroids by day 3:

1. Infliximab: 5 mg/kg IV at weeks 0,2, and 6 1
2. Cyclosporine: 2 mg/kg/day IV 1
3. Colectomy: Should be considered if no improvement after 4-7 days of rescue therapy 1

Common Pitfalls to Avoid

• Delaying assessment of response to IV steroids beyond day 3 1, 2
• Prolonging IV steroid use beyond 7-10 days without considering alternatives 1, 2
• Failing to involve colorectal surgeons early in the management 1, 2
• Inadequate thromboprophylaxis 1, 2

Emerging Therapies

Recent research suggests potential benefits of adding tofacitinib to IV corticosteroids in ASUC, with one randomized controlled trial showing improved response rates (83% vs 59%) and decreased need for rescue therapy 3. However, this approach is not yet incorporated into major guidelines.