What are the management guidelines for ulcerative colitis?

Management Guidelines for Ulcerative Colitis

For patients with ulcerative colitis (UC), treatment should be tailored based on disease extent, severity, and location, with 5-aminosalicylates (5-ASA) as first-line therapy for mild-to-moderate disease and escalation to corticosteroids, immunomodulators, or biologics for moderate-to-severe disease or those who fail initial therapy. 1

Classification and Assessment

• Disease extent should be classified according to the Montreal Classification (proctitis, left-sided, or extensive) to guide appropriate therapy 2
• Disease severity should be assessed using validated scoring systems such as the Mayo Score to determine appropriate treatment strategy 2
• Evaluate for extraintestinal manifestations which occur in approximately 27% of patients with UC 2

Management of Mild-to-Moderate UC

Extensive Disease

• First-line therapy: Standard dose mesalamine (2-3 grams/day) or diazo-bonded 5-ASA rather than low-dose mesalamine, sulfasalazine, or no treatment 1
• Add rectal mesalamine to oral 5-ASA therapy for better outcomes 1
• For suboptimal response to standard-dose mesalamine or moderate disease activity, use high-dose mesalamine (>3 grams/day) with rectal mesalamine 1
• Once-daily dosing of oral mesalamine is preferred over multiple daily dosing for better adherence 1

Proctosigmoiditis or Proctitis

• Mesalamine enemas or suppositories are preferred over oral mesalamine for distal disease 1
• For proctitis specifically, mesalamine suppositories are strongly recommended 1
• For patients who choose rectal therapy, mesalamine enemas are preferred over rectal corticosteroids 1
• For patients intolerant or refractory to mesalamine suppositories, rectal corticosteroid therapy is suggested 1

Treatment-Refractory Mild-to-Moderate UC

• For patients refractory to optimized oral and rectal 5-ASA, add either oral prednisone or budesonide MMX 1
• Monitor renal function periodically in patients on 5-ASA therapy 1

Management of Moderate-to-Severe UC

• Oral corticosteroid therapy (prednisolone 40 mg daily) is appropriate for induction of remission 1
• After successful induction with corticosteroids, transition to maintenance therapy with 5-ASA, thiopurines, anti-TNF agents (with or without thiopurine/methotrexate), or vedolizumab 1
• For corticosteroid-resistant/dependent UC, anti-TNF therapy or vedolizumab is recommended 1
• Biologics available for moderate-to-severe UC include:
  • Infliximab: 5 mg/kg at weeks 0,2, and 6, then every 8 weeks 3
  • Vedolizumab: 300 mg IV at weeks 0,2, and 6, then every 8 weeks, or 108 mg subcutaneously every 2 weeks after IV induction 4

Management of Severe UC

• Severe UC should be managed jointly by a gastroenterologist and colorectal surgeon 1
• Daily physical examination to evaluate abdominal tenderness and rebound tenderness 1
• Monitor vital signs four times daily, maintain stool chart, and perform regular laboratory tests (FBC, ESR/CRP, electrolytes, albumin) 1
• Provide intravenous fluid and electrolyte replacement, maintain hemoglobin >10 g/dl 1
• Administer subcutaneous heparin to reduce thromboembolism risk 1
• For patients with acute severe UC refractory to IV corticosteroids, infliximab or cyclosporine may be considered 1
• Patients should be informed of a 25-30% chance of needing colectomy 1

Maintenance Therapy

• Lifelong maintenance therapy is generally recommended, especially for patients with left-sided or extensive disease 1
• Patients should normally receive maintenance therapy with aminosalicylates, azathioprine, or mercaptopurine to reduce relapse risk 1
• Maintenance therapy may also reduce the risk of colorectal cancer 1
• Patients in remission with biologics and/or immunomodulators after prior failure of 5-ASA may discontinue 5-aminosalicylates 1

Monitoring and Follow-up

• Regular monitoring of symptoms and biomarkers of inflammation (e.g., fecal calprotectin) 2
• Colonoscopy at 8 years from diagnosis for surveillance of dysplasia 2
• Timely assessments of response and remission are critical to ensuring optimal outcomes 1

Treatment Considerations and Caveats

• Patients already on sulfasalazine in remission or with prominent arthritic symptoms may reasonably choose sulfasalazine 2-4g/day if alternatives are cost-prohibitive, despite higher intolerance rates 1
• Probiotics, curcumin, and fecal microbiota transplantation are not currently recommended for routine use in UC due to insufficient evidence 1
• Patients who place higher value on convenience may choose oral mesalamine over rectal therapy, though this may be less effective 1
• Biologic therapy carries risks including serious infections and malignancies, requiring careful patient selection and monitoring 3