What is the initial treatment for an acute exacerbation of ulcerative colitis?

Initial Treatment for Acute Exacerbation of Ulcerative Colitis

For an acute exacerbation of ulcerative colitis, the initial treatment should be based on disease severity, with oral 5-ASA (mesalamine) 2-4.8g daily plus rectal 5-ASA for mild-to-moderate disease, and oral prednisolone 40mg daily for moderate-to-severe disease.

Disease Severity Assessment

The treatment approach depends on the severity of the exacerbation:

Mild to Moderate Disease

• Characterized by:
  • <4-6 stools per day
  • Minimal blood in stool
  • Normal vital signs
  • No systemic symptoms
  • Normal or mildly elevated inflammatory markers

Moderate to Severe Disease

• Characterized by:

  • 6 stools per day

  • Frequent blood in stool
  • Fever, tachycardia
  • Anemia
  • Elevated inflammatory markers

Treatment Algorithm

For Mild to Moderate Disease:

1. First-line therapy: Oral 5-ASA (mesalamine) 2-3g/day 1, 2

   • Add rectal 5-ASA enemas for enhanced efficacy 1
   • For patients already on 5-ASA maintenance who are flaring, escalate to 4-4.8g/day orally plus rectal 5-ASA 1
   • Administer with food and ensure adequate hydration 3

2. If inadequate response to 5-ASA within 2 weeks:

   • Add oral prednisolone 40mg daily with a taper over 6-8 weeks 1
   • Alternative for those wishing to avoid systemic steroids: budesonide MMX 9mg daily 1

For Moderate to Severe Disease:

1. First-line therapy: Oral prednisolone 40mg daily with a taper over 6-8 weeks 1, 2

   • The 40mg dose has been shown to be more effective than 20mg/day 1

2. For hospitalized patients with severe disease:

   • Intravenous corticosteroids (methylprednisolone 60mg/day or hydrocortisone 100mg four times daily) 2
   • IV fluid and electrolyte replacement 2
   • Nutritional support if malnourished 2

3. If no improvement after 3 days of IV corticosteroids:

   • Consider rescue therapy with infliximab 5mg/kg IV or cyclosporine 2mg/kg/day IV 2

Monitoring During Treatment

• Daily physical examination to assess abdominal tenderness 2
• Monitor vital signs and stool frequency 2
• Laboratory tests every 24-48 hours (CBC, electrolytes, albumin) 2
• Renal function monitoring for patients on 5-ASA therapy 1, 3
• Abdominal imaging if colonic dilation is present or clinical deterioration occurs 2

Important Considerations and Pitfalls

• Avoid delaying treatment escalation in non-responders 2
• Avoid prolonged steroid use without implementing steroid-sparing strategies 2
• Avoid opioids when possible due to risks of dependence and gut dysmotility 2
• Consider surgical consultation early for severe cases not responding to medical therapy 2
• Monitor for 5-ASA nephrotoxicity with regular renal function tests 1, 3
• Watch for mesalamine-induced acute intolerance syndrome which may mimic an UC flare 3

Maintenance Therapy After Acute Exacerbation

After achieving remission:

• For mild-moderate disease: continue mesalamine ≥2g/day 2
• For patients requiring two or more courses of corticosteroids in the past year: escalate to thiopurines, anti-TNF therapy, vedolizumab, or tofacitinib 1

The treatment approach should be timely and effective to induce remission quickly, reduce morbidity and mortality, and improve quality of life for patients with ulcerative colitis.