What is the management approach for an acute exacerbation of ulcerative colitis?

Management of Acute Exacerbation of Ulcerative Colitis

Treatment of acute exacerbation of ulcerative colitis should be tailored to 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 the appropriate treatment approach:

• Mild: <4 stools daily, minimal blood, no systemic symptoms
• Moderate: 4-6 bloody stools daily, mild systemic symptoms
• Severe: >6 bloody stools daily, systemic symptoms (fever, tachycardia, anemia, elevated CRP/ESR) 1

Treatment Algorithm by Severity

Mild Disease

1. First-line: Oral 5-ASA (mesalamine) 2-4.8 g/day 1, 2
   • Add topical 5-ASA for distal disease: suppositories (1g) for proctitis or enemas (1-4g) for left-sided disease 3
   • Combination of oral and topical 5-ASA is more effective than either alone 3
2. Assess response within 2 weeks 1
3. If inadequate response: Add topical corticosteroids (e.g., 5 mg prednisolone suppository) 3
4. If still inadequate: Escalate to oral prednisolone 40 mg daily 3

Moderate Disease

1. First-line: Oral prednisolone 40 mg daily 3, 1
   • Can add 5-ASA therapy as adjunctive treatment 3
   • Taper prednisolone gradually over 8 weeks according to response 3
2. Assess response within 3-5 days 1
3. If inadequate response: Consider hospitalization and IV steroids if worsening 1

Severe Disease (Requires Hospitalization)

1. First-line: IV methylprednisolone 40-60 mg/day or hydrocortisone 100 mg four times daily 3, 1
2. Supportive care:
   • IV fluid and electrolyte replacement
   • Subcutaneous prophylactic low-molecular-weight heparin
   • Nutritional support if malnourished
   • Daily physical examination for abdominal tenderness
   • Monitor vital signs, stool frequency, and consistency
   • Laboratory tests every 24-48 hours (CBC, electrolytes, albumin, CRP) 3, 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 at 0,2, and 6 weeks, then every 8 weeks 3, 4
   • Cyclosporine 2 mg/kg/day IV 3
5. If no improvement after 4-7 days of rescue therapy: Consider colectomy 1

Special Considerations

Proctitis (Distal Disease)

• First-line: 1 g 5-ASA suppository once daily (usually at night) 3
• If incomplete response: Add oral 5-ASA 2-3 g daily 3
• If still inadequate: Add corticosteroid suppository and optimize oral 5-ASA to 4-4.8 g daily 3

Proximal Constipation

• Treat with stool bulking agents or laxatives if present 3
• Can exacerbate distal disease symptoms if not addressed

Monitoring During Treatment

• Mild-Moderate Disease: Clinical assessment at 2 weeks
• Severe Disease:
  • Daily physical examination
  • Vital signs four times daily
  • Stool chart recording number and character of bowel movements
  • Laboratory tests every 24-48 hours
  • Abdominal imaging if clinical deterioration or suspicion of toxic megacolon 3, 1

Indications for Surgery

• Perforation
• Massive hemorrhage
• Toxic megacolon unresponsive to medical therapy
• Failure to respond to maximal medical therapy 1

Maintenance Therapy After Acute Exacerbation

• For mild disease: Continue 5-ASA at maintenance dose of 2-2.4 g/day 1, 2
• For moderate-severe disease requiring steroids: Consider thiopurines, anti-TNF therapy, vedolizumab, or tofacitinib to prevent recurrence 1
• Lifelong maintenance therapy is generally recommended, especially for left-sided or extensive disease 3

Common Pitfalls to Avoid

• Delaying treatment escalation in non-responders, which increases morbidity and mortality
• Prolonged steroid use without appropriate steroid-sparing strategies
• Failing to assess for complications like toxic megacolon or perforation in severe disease
• Inadequate dosing of 5-ASA (efficacy is dose-dependent) 5
• Not addressing proximal constipation, which can worsen distal symptoms 3

Recent evidence suggests that combining mesalamine with corticosteroids does not provide additional benefit over corticosteroids alone in hospitalized patients with acute severe ulcerative colitis 6, though there may be a signal for reduced need for biologics at 90 days that requires further evaluation.