What treatment options are available for a patient with ulcerative colitis who can no longer receive regular infusions and is currently taking high-dose prednisone and Lialda (mesalamine)?

Treatment Options for Ulcerative Colitis When Infusions Are Unavailable

For a patient with ulcerative colitis who can no longer receive infusions and is currently on high-dose prednisone and Lialda (mesalamine), I recommend optimizing oral and rectal mesalamine therapy while implementing a careful prednisone taper, with consideration of adding azathioprine as a steroid-sparing agent if remission cannot be maintained.

Assessment of Current Therapy

The patient is currently on:

• High-dose prednisone for 3-4 weeks
• Lialda (oral mesalamine)
• Previously on infusion therapy (likely infliximab or vedolizumab based on guidelines)

Treatment Algorithm

Step 1: Optimize 5-ASA Therapy

• Increase oral mesalamine (Lialda) to high-dose therapy (>3 grams/day) if not already at this dose 1
• Add rectal mesalamine (enemas or suppositories) to oral therapy 1, 2
  • For left-sided colitis: mesalamine enemas 1g daily
  • For proctitis: mesalamine suppositories 1g daily
• Consider once-daily dosing of oral mesalamine to improve adherence 1, 2

Step 2: Prednisone Management

• Continue current prednisone dose until clinical improvement is observed
• Begin slow taper of prednisone by decreasing dose in small increments (5-10mg per week) 3
• Aim to taper completely over 6-8 weeks to minimize risk of adrenal suppression 1
• Monitor closely for signs of disease flare during taper

Step 3: Add Steroid-Sparing Agent

• If unable to taper prednisone without disease flare, add azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.5 mg/kg/day) as a steroid-sparing maintenance therapy 1, 2
• These immunomodulators have been shown to be effective for maintenance of steroid-induced remission in UC 1

Step 4: Consider Alternative Biologics

• If the patient previously received infliximab infusions, consider switching to adalimumab (self-administered subcutaneous injections) 1
• While adalimumab is less effective than infliximab or vedolizumab for induction of remission, it offers the convenience of self-administration 1

Important Considerations

Medication Efficacy

• High-dose mesalamine combined with rectal therapy can achieve remission in up to 80% of patients with left-sided colitis 4
• Prolonged high-dose oral prednisone (≥40mg) can induce remission in 67% of patients overall, with rates varying by disease severity (84% in mild disease, 80% in moderate disease, 47% in severe disease) 5

Monitoring

• Regular assessment of inflammatory markers (C-reactive protein, fecal calprotectin) to objectively evaluate disease activity 2
• If symptoms worsen during prednisone taper, pause the taper and consider increasing the dose temporarily before resuming a slower taper 3

Potential Pitfalls

1. Mesalamine sensitivity: Rarely, patients may experience paradoxical worsening of colitis with mesalamine. If symptoms worsen after optimizing mesalamine therapy, consider mesalamine sensitivity 6

2. Steroid dependence: Extended use of corticosteroids leads to significant adverse effects. If unable to taper below 10-15mg of prednisone without disease flare after adding an immunomodulator, reconsider the need for alternative biologic therapy 1, 2

3. Medication adherence: Non-adherence to mesalamine is common and associated with higher relapse rates. Once-daily dosing may improve adherence 1, 2

Follow-up

• Assess response to optimized therapy within 2-4 weeks 2
• If no improvement or worsening symptoms with systemic features (fever, significant anemia, severe pain), consider hospitalization for IV corticosteroids 1

This treatment approach aims to maintain disease control while minimizing corticosteroid exposure in a patient who can no longer receive infusion therapy. The combination of optimized oral and rectal mesalamine with a careful prednisone taper offers the best chance of maintaining remission while transitioning to a sustainable long-term maintenance regimen.