What is the treatment for a flare of ulcerative colitis (UC) with fever?

Treatment for Ulcerative Colitis Flare with Fever

For a flare of ulcerative colitis with fever, immediate treatment should include intravenous corticosteroids (methylprednisolone 60 mg/day or hydrocortisone 100 mg four times daily), intravenous fluid resuscitation, and testing for Clostridioides difficile and other enteric pathogens before starting immunosuppressive therapy. 1

Initial Assessment and Management

When a patient presents with a UC flare accompanied by fever, this should be considered a severe flare requiring prompt intervention:

• Severity assessment: According to Truelove and Witts criteria, patients with bloody stool frequency ≥6/day plus one of the following: tachycardia (>90 bpm), temperature >37.8°C, anemia (hemoglobin <10.5 g/dl), or elevated ESR (>30 mm/h) or CRP (>30 mg/l) have severe UC 2

• Diagnostic workup:

  • Complete blood count, inflammatory markers (CRP or ESR)
  • Electrolytes and liver function tests
  • Stool sample for culture and C. difficile toxin assay 1
  • Fecal calprotectin (>150 mg/g indicates active inflammation) 2

Treatment Algorithm

1. Severe UC with Fever (Hospital Admission Required)

• Immediate interventions:

  • Joint management by gastroenterologist and colorectal surgeon
  • IV corticosteroids (methylprednisolone 60 mg/day or hydrocortisone 100 mg four times daily)
  • IV fluid resuscitation and electrolyte replacement
  • Venous thromboembolism prophylaxis
  • NPO status if severe symptoms or risk of perforation 1

• Infection control:

  • Test for C. difficile and other pathogens before starting immunosuppressive therapy
  • If C. difficile positive, treat with vancomycin 125mg orally four times daily 1

• Monitoring:

  • Daily vital signs, abdominal examination
  • Stool frequency and character
  • Laboratory monitoring (CBC, CRP, electrolytes, albumin, liver function tests) 1

2. Moderate UC with Fever (May Require Hospitalization)

• Treatment options:
  • Oral corticosteroids (prednisone 40-60 mg daily) if patient can tolerate oral intake
  • High-dose oral mesalamine (5-ASA) 4 g/day combined with topical mesalamine for left-sided disease 2, 3
  • Consider early introduction of rescue therapy (infliximab, cyclosporine) if no improvement within 3-5 days 1

3. Mild UC with Fever

• Treatment approach:
  • Rule out infection (especially C. difficile)
  • Oral mesalamine 2-4 g/day
  • Topical mesalamine (suppositories for proctitis, enemas for left-sided disease) 2, 4
  • Short course of oral corticosteroids if inadequate response 1

Response Assessment and Follow-up

• Assess clinical response within 3-7 days of initiating therapy
• Monitor stool frequency, bleeding, abdominal pain, and vital signs
• Check laboratory markers (WBC, CRP, albumin)
• Perform endoscopic assessment after 4-8 weeks to confirm mucosal healing 1

Special Considerations and Pitfalls

• Infection risk: Always rule out C. difficile infection, which can mimic or exacerbate UC flares. Failure to identify this can lead to inappropriate immunosuppression and clinical deterioration 1, 5

• Surgical indications: Consider emergency surgery for free perforation, massive hemorrhage, generalized peritonitis, toxic megacolon not responding to medical therapy, or clinical deterioration despite appropriate medical management 1

• Medication considerations:

  • Aminosalicylates remain first-line for mild-moderate disease but are insufficient alone for severe flares with fever 6
  • When starting biologics like infliximab, ensure infection has been ruled out 1

• Common pitfalls:

  • Inadequate initial resuscitation can lead to complications; ensure proper fluid and electrolyte replacement
  • Overlooking VTE prophylaxis can increase thrombotic risk, which is already elevated in active UC
  • Delaying surgical consultation in severe cases can lead to worse outcomes 1

Maintenance Therapy After Flare Resolution

Once the acute flare resolves:

• Continue mesalamine (2-4g/day) as maintenance therapy
• Consider immunomodulators (azathioprine, mercaptopurine) for steroid-dependent disease
• For refractory disease, biologics such as infliximab, vedolizumab, or ustekinumab may be necessary 1, 3