What is the treatment approach for ulcerative colitis?

Treatment Approach for Ulcerative Colitis

The treatment of ulcerative colitis should follow a stepwise approach based on disease severity and extent, with oral and/or topical mesalamine (5-ASA) as first-line therapy for mild-to-moderate disease, corticosteroids for moderate-to-severe disease, and advanced therapies including biologics for refractory cases. 1, 2

Disease Assessment and Classification

• Classify disease by:
  • Extent: Proctitis, proctosigmoiditis, left-sided, or pancolitis
  • Severity: Mild, moderate, or severe based on symptoms and inflammatory markers
  • Confirm diagnosis with sigmoidoscopy/colonoscopy and exclude infection before starting treatment 2

Treatment Algorithm by Disease Severity

Mild-to-Moderate Disease

1. First-line therapy:

   • Distal disease (proctitis/proctosigmoiditis):

     • Topical mesalamine (suppositories for proctitis, enemas for proctosigmoiditis) 1
     • Consider combination with oral mesalamine for better efficacy 1

   • Left-sided or extensive disease:

     • Oral mesalamine 2-4g daily (standard dose) 1, 2
     • Once-daily dosing is as effective as multiple daily doses 1

2. If inadequate response after 2-4 weeks:

   • Add topical therapy if not already using
   • Consider oral prednisone 40mg daily or budesonide MMX 1, 2

Moderate-to-Severe Disease

1. Inpatient management for severe disease:

   • IV corticosteroids (hydrocortisone 400mg/day or methylprednisolone 60mg/day) 1, 2
   • Close monitoring with:
     • Daily physical examination
     • Vital signs four times daily
     • Stool chart documentation
     • Laboratory monitoring every 24-48 hours
     • Abdominal radiography if colonic dilatation present 1

2. Supportive care:

   • IV fluid and electrolyte replacement
   • Blood transfusion to maintain hemoglobin >10 g/dl
   • Subcutaneous heparin for thromboembolism prophylaxis
   • Nutritional support if malnourished 1, 2

3. If no response to IV steroids:

   • Consider biologic agents (infliximab, etc.) 2, 3
   • Joint management with colorectal surgeon (25-30% may need colectomy) 1

Refractory Disease

For patients failing conventional therapy:

1. Immunomodulators:

   • Azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.5 mg/kg/day) 2

2. Biologic agents:

   • Anti-TNF agents (e.g., infliximab 5 mg/kg at weeks 0,2, and 6, then every 8 weeks) 3
   • Anti-integrin agents (e.g., vedolizumab)
   • IL-12/23 inhibitors (e.g., ustekinumab)
   • JAK inhibitors
   • S1P receptor modulators 2, 4

3. Combination therapy:

   • Anti-TNF agents are more effective when combined with immunomodulators 2
   • Early use of biologics with/without immunomodulators is recommended for patients at high risk of colectomy 2

Maintenance Therapy

• Lifelong maintenance therapy is generally recommended for all patients, especially those with left-sided or extensive disease 1, 2
• Maintenance options:
  • Mesalamine ≥2g/day (first-line) 2
  • Azathioprine or mercaptopurine for frequent relapses or steroid-dependent disease 2
  • Continue biologic therapy in those who responded to induction 3

Important Considerations and Monitoring

• Medication safety:

  • Monitor renal function periodically with 5-ASA therapy 1
  • Screen for tuberculosis and other infections before starting biologics 3
  • Be aware of potential increased risk of lymphoma and other malignancies with TNF blockers 3

• Disease monitoring:

  • Regular assessment of symptoms and inflammatory markers
  • Colonoscopy surveillance beginning 8 years after diagnosis 4

Surgical Management

• Consider surgery for:
  • Hemodynamic instability or shock
  • Perforation with peritonitis
  • Failure of medical therapy
  • Persistent severe symptoms despite optimal treatment 2

The treatment approach should be adjusted based on patient response, with the goal of achieving and maintaining clinical remission, promoting mucosal healing, avoiding surgical intervention, and decreasing the risk of colorectal cancer 5, 4.