What is the recommended treatment for colitis in an inpatient setting?

Management of Colitis in the Inpatient Setting

For patients with acute severe ulcerative colitis requiring hospitalization, intravenous corticosteroids (methylprednisolone 40-60 mg daily or hydrocortisone 100 mg four times daily) are the first-line treatment. 1, 2

Initial Assessment and Management

Diagnostic Evaluation

• Perform urgent inpatient assessment including:
  • Blood tests (FBC, CRP, U&E, LFTs, magnesium)
  • Stool culture and C. difficile assay
  • Radiological imaging (AXR or CT)
  • Unprepared flexible sigmoidoscopy with biopsy 1, 2

First-Line Treatment

• Intravenous corticosteroids:
  • Methylprednisolone 40-60 mg daily OR
  • Hydrocortisone 100 mg four times daily 1, 2
  • Single daily dosing is as effective as split-dosing and causes less adrenal suppression 1
  • Duration of IV corticosteroid therapy: 7-10 days 2
  • Higher doses of IV corticosteroids are not more effective 1, 2

Supportive Care

• IV fluid and electrolyte replacement (potassium supplementation ≥60 mmol/day)
• Subcutaneous low-molecular-weight heparin for thromboprophylaxis
• Nutritional support for malnourished patients (enteral preferred over parenteral)
• Blood transfusion to maintain hemoglobin above 8-10 g/dl 2

Monitoring Response

Assessment of Response

• Assess response to IV corticosteroids by day 3 2
• Poor response indicators include:
  • Persistent symptoms
  • Elevated inflammatory markers

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

• Daily monitoring of:
  • Vital signs
  • Stool frequency
  • Laboratory parameters
  • Abdominal radiography if colonic dilatation is present (transverse colon >5.5 cm) 2

Rescue Therapy for Non-Responders

For Patients Not Responding to IV Steroids by Day 3:

• Infliximab: 5 mg/kg IV at weeks 0,2, and 6 OR
• Cyclosporine: 2 mg/kg/day IV 2, 1

Considerations for Rescue Therapy Selection:

• Infliximab advantages:
  • Better short-term safety profile
  • Option for maintenance treatment
  • Preferred in patients already exposed to immunosuppressives 3
• Cyclosporine advantages:
  • Rapid onset of action
  • Short half-life
  • Can be used as monotherapy in patients who should avoid steroids 2, 3

Surgical Management

Indications for Colectomy:

• No improvement after 4-7 days of rescue therapy
• Failure to respond to medical therapy within 48-72 hours
• Toxic megacolon with clinical deterioration
• Free perforation
• Life-threatening hemorrhage 2

Surgical Consultation:

• Early involvement of colorectal surgeons is essential
• Delayed surgical consultation can lead to poor outcomes 2

Discharge Planning and Follow-up

Discharge Criteria:

• Resolution of rectal bleeding (Mayo subscore 0-1)
• Stool frequency returned to baseline frequency and form (Mayo subscore 0-1)
• Stability for 24 hours before discharge 4

Discharge Medications:

• Appropriate to discharge on 40 mg prednisone with tapering over 6-8 weeks 1, 4
• Consider initiating maintenance therapy:
  • For anti-TNF-naïve patients: anti-TNF therapy
  • For anti-TNF-exposed patients: vedolizumab or ustekinumab 4

Follow-up:

• Clinical follow-up within 2 weeks
• Lower endoscopy within 4-6 months after discharge 4

Common Pitfalls to Avoid

• Delaying assessment of response to IV steroids beyond day 3
• Prolonging IV steroid use beyond 7-10 days without considering alternatives
• Failing to involve colorectal surgeons early in management
• Inadequate thromboprophylaxis
• Using routine adjunctive antibiotics unless specific infection is suspected 2
• Prolonging treatment with high-dose oral corticosteroids, which has diminishing chance of achieving remission and increases risk of complications 1

Maintenance Therapy After Acute Episode

For patients who respond to initial treatment, maintenance therapy should be initiated to prevent relapse:

• 5-ASA for mild disease
• Thiopurines, anti-TNF therapy, vedolizumab, or tofacitinib for moderate-severe disease 1
• Consider combination therapy with TNF antagonists and immunomodulators rather than monotherapy 1