Does ulcerative colitis have flares?

Ulcerative Colitis and Disease Flares

Yes, ulcerative colitis is characterized by a relapsing and remitting course with disease flares that can vary in frequency and severity. 1, 2

Understanding UC Flares

Ulcerative colitis (UC) is a chronic inflammatory bowel disorder affecting the colon and rectum, with a disease course marked by periods of:

• Acute inflammation (flares)
• Low-grade chronic inflammatory activity
• Remission

Flare Characteristics

• Frequency: Can range from weekly to yearly
  • 27.9% of patients experience ≥1 flare per week
  • 25.1% experience ≥1 flare per month 3
• Duration: Most flares (76.5%) last ≤7 days 3
• Severity: Typically classified as mild, moderate, or severe
  • 51.9% of flares are moderate in severity 3
  • Approximately 20% of UC patients will experience a severe flare requiring hospitalization during their disease course 4

Clinical Presentation of Flares

Flares typically manifest as:

• Bloody diarrhea with or without mucus
• Rectal urgency and tenesmus
• Abdominal pain (often relieved by defecation)
• In severe cases: fever, tachycardia, and weight loss 2

Monitoring and Diagnosing Flares

Biomarkers for Flare Detection

The American Gastroenterological Association (AGA) recommends using:

• Fecal calprotectin >150 μg/g
• Elevated fecal lactoferrin
• Elevated C-reactive protein (CRP)

These markers can help confirm active inflammation in patients with moderate to severe symptoms suggestive of a flare 1, 5.

Symptom and Biomarker Correlation

• In patients with moderate to severe symptoms (frequent rectal bleeding, significantly increased stool frequency):

  • Elevated biomarkers reliably suggest moderate to severe endoscopic inflammation
  • Treatment adjustments can be made without routine endoscopic assessment 1

• In patients with mild symptoms:

  • Biomarkers may not accurately reflect endoscopic inflammation
  • Endoscopic assessment is recommended before treatment adjustment 1

Management of Flares

Treatment Approach Based on Severity

1. Mild to moderate flares:

   • First-line: 5-aminosalicylic acid (5-ASA) medications
   • Common approach: Increasing the dose of current medication (60.4% of patients) 3

2. Moderate to severe flares:

   • Oral corticosteroids for induction of remission
   • Combined oral and topical 5-ASA drugs
   • Addition of corticosteroids to treatment regimen (34.5% of patients) 3

3. Severe flares requiring hospitalization:

   • Intravenous corticosteroids as first-line treatment
   • Rescue therapy with ciclosporin or infliximab for steroid-refractory cases
   • Close monitoring of symptoms, CRP, and albumin levels
   • Timely colectomy if medical therapy fails 4

Monitoring Response to Treatment

• Regular assessment of symptoms
• Serial monitoring of fecal calprotectin and other inflammatory markers
• Endoscopic evaluation when needed 6

Important Clinical Considerations

Differential Diagnosis During Flares

• Always exclude superimposed infections:
  • Test for Clostridioides difficile
  • Rule out other enteric pathogens 1, 5

Predictors of Flare Risk

• Elevated calprotectin in patients with quiescent UC can predict clinical relapse with >85% sensitivity and specificity
• Rising fecal lactoferrin levels may predict clinical flares 5

Long-term Impact of Flares

• Recurrent flares can lead to decreased quality of life
• Approximately 7% of patients require colectomy within 5 years of diagnosis
• UC patients have approximately 5 years shorter life expectancy compared to the general population 6

By understanding the pattern of flares in UC and utilizing appropriate biomarkers and treatment strategies, clinicians can better manage this chronic relapsing and remitting condition and improve patient outcomes.