What is the management for acute exacerbation of ulcerative colitis?

Management of Acute Exacerbation of Ulcerative Colitis

For acute exacerbation of ulcerative colitis, the first-line treatment depends on disease severity, with intravenous methylprednisolone 40-60 mg/day for severe disease, oral prednisolone 40 mg daily for moderate disease, and 5-ASA therapy for mild disease. 1

Disease Severity Assessment

Disease severity determines treatment approach:

• Mild exacerbation: Fewer than 4 stools daily, minimal blood, no systemic symptoms
• Moderate exacerbation: 4-6 bloody stools daily, mild systemic symptoms
• Severe exacerbation: More than 6 bloody stools daily, systemic symptoms (fever, tachycardia, anemia, elevated ESR/CRP)

Treatment Algorithm Based on Severity

Mild Exacerbation

1. Oral 5-ASA (mesalamine): 2-4.8 g/day 1, 2
2. Add topical 5-ASA: Suppositories (1g) for proctitis or enemas (1-4g) for left-sided disease 1
3. Monitor response: Assess within 2 weeks
4. If inadequate response: Escalate to oral prednisolone

Moderate Exacerbation

1. Oral prednisolone: 40 mg daily with 6-8 week taper 1
2. Alternative: Budesonide MMX 9 mg daily for patients wishing to avoid systemic corticosteroids 1
3. Monitor response: Assess within 3-5 days
4. If inadequate response: Consider hospitalization and IV steroids

Severe Exacerbation (Requires Hospitalization)

1. IV methylprednisolone: 40-60 mg/day or hydrocortisone 100 mg four times daily 1, 3
2. Supportive care:
   • IV fluid and electrolyte replacement
   • Subcutaneous prophylactic low-molecular-weight heparin
   • Nutritional support if malnourished
   • Withdrawal of anticholinergics, antidiarrheals, NSAIDs, and opioids
   • Blood transfusion if hemoglobin below 8-10 g/dl 1
3. Assess response by day 3 1
4. If no response to IV steroids by day 3:
   • Initiate rescue therapy with either infliximab 5 mg/kg IV or cyclosporine 2 mg/kg/day IV 1, 4
   • Consider colectomy if no improvement after 4-7 days of rescue therapy 1

Monitoring During Acute Exacerbation

• Daily physical examination for abdominal tenderness
• Monitor vital signs, stool frequency, and consistency
• Laboratory tests every 24-48 hours (CBC, electrolytes, albumin, CRP) 3
• Abdominal imaging if clinical deterioration or suspicion of toxic megacolon 3

Important Considerations and Pitfalls

• Avoid delaying treatment escalation in non-responders, as this increases morbidity and mortality 1
• Avoid prolonged steroid use without appropriate steroid-sparing strategies 3
• Avoid opioids when possible due to risks of dependence and gut dysmotility 3
• Screen for infections before immunosuppressive therapy, particularly TB prior to biologics 3, 4
• Monitor renal function in patients on 5-ASA therapy due to risk of nephrotoxicity 1, 2
• Avoid antibiotics in acute severe UC without evidence of infection 1

Maintenance Therapy After Acute Exacerbation

• For patients who required steroids: Consider thiopurines, anti-TNF therapy, vedolizumab, or tofacitinib to prevent recurrence 1
• For mild disease: Continue 5-ASA at maintenance dose of 2-2.4 g/day 2, 5
• Consider discontinuing 5-ASA in patients who achieve remission with biologics and/or immunomodulators 1

Surgical Considerations

• Indications for urgent colectomy: Perforation, massive hemorrhage, toxic megacolon unresponsive to medical therapy 3
• Surgical procedure of choice: Subtotal colectomy with ileostomy for acute severe disease 3

By following this evidence-based approach to managing acute exacerbations of ulcerative colitis, clinicians can optimize outcomes and minimize complications for patients with this challenging condition.