What is the management of ulcerative colitis?

Management of Ulcerative Colitis

The management of ulcerative colitis should follow a step-wise approach based on disease severity, with 5-aminosalicylates (5-ASA) as first-line therapy for mild-to-moderate disease and early biologic therapy for moderate-to-severe disease. 1

Disease Severity Assessment and Initial Treatment

Mild-to-Moderate Disease

• First-line therapy: Mesalamine (5-ASA) 4g daily oral with potential addition of topical therapy 1
  • Start at optimal dosages (4.8g per day of active 5-ASA) rather than escalating from lower doses 2
  • Once-daily dosing is comparable to multiple daily dosing for adherence and efficacy 3
  • Combined oral and rectal 5-ASA therapy is superior to oral therapy alone 3

Moderate-to-Severe Disease

• First-line therapy: Early use of biologic agents with or without immunomodulator therapy 3
  • Patients with less severe disease who prioritize safety over efficacy may choose gradual step-up therapy with 5-ASA 3
• Corticosteroids: Oral prednisolone 40mg daily for moderate disease; IV steroids (methylprednisolone 60mg/day or hydrocortisone 400mg/day) for severe disease 1
• Rescue therapy: If no improvement after 3 days of IV corticosteroids, initiate infliximab 5mg/kg IV or cyclosporine 2mg/kg/day IV 1

Maintenance Therapy

• All patients should receive maintenance therapy to prevent relapse 1

• Options include:

  • Oral mesalamine ≥2g/day
  • Immunomodulators (azathioprine or mercaptopurine)
  • Biologics (infliximab, adalimumab, golimumab, vedolizumab, ustekinumab)
  • Tofacitinib (JAK inhibitor)
  • Ozanimod (sphingosine-1-phosphate modulator) 4

• Important consideration: The AGA suggests against continuing 5-aminosalicylates for maintenance in patients who have achieved remission with biologics and/or immunomodulators 3

Biologic Therapy Considerations

• Infliximab: 5mg/kg at weeks 0,2, and 6, then every 8 weeks for ulcerative colitis 5

  • For patients who respond then lose response, consider increasing to 10mg/kg 5
  • Combination therapy with thiopurines is superior to thiopurine monotherapy 3
  • Consider combination therapy for patients with unfavorable pharmacokinetics (severe disease, higher inflammatory burden, low albumin, higher BMI) 3

• Screening before biologics: Test for latent TB and treat if positive before starting infliximab or other biologics 5

• Monitoring: Watch for serious infections, including TB, invasive fungal infections, and opportunistic pathogens 5

Surgical Management

• Surgical intervention is indicated for:

  • Intestinal perforation
  • Massive hemorrhage
  • Documented intestinal ischemia
  • Intestinal obstruction not responding to medical treatment
  • Clinical deterioration or signs of shock 1

• Subtotal colectomy with ileostomy is the surgical treatment of choice for severe complications 1

Monitoring and Follow-up

• Regular assessment of symptoms, physical examination, and laboratory monitoring
• Endoscopic evaluation to confirm mucosal healing
• Laboratory tests (complete blood count, electrolytes, albumin) every 24-48 hours in severe cases 1
• Colonoscopy at 8 years from diagnosis for surveillance of dysplasia 4

Common Pitfalls to Avoid

• Delaying treatment escalation in non-responders
• Prolonged steroid use without steroid-sparing strategies
• Failure to recognize infectious causes
• Delaying surgical consultation in severe cases
• Routine use of antibiotics without evidence of infection
• Using opioids (risks of dependence, infection, narcotic bowel syndrome, gut dysmotility) 1
• Not screening for TB before immunosuppressive therapy 1

Long-term Considerations

• UC patients have a lower life expectancy (approximately 5 years shorter than general population) 4
• Increased risk for colectomy (approximately 7% within 5 years of diagnosis) 4
• Increased risk for colorectal cancer (4.5% after 20 years of disease duration) 4
• Regular monitoring is essential for early detection of complications and disease progression 1