What is the initial treatment approach for an ulcerative colitis flare?

Initial Treatment Approach for Ulcerative Colitis Flare

The initial treatment for an ulcerative colitis flare should be a combination of topical mesalazine 1 g/day with oral mesalazine ≥ 2.4 g/day, which is more effective than either treatment alone for controlling inflammation and symptoms. 1, 2

Treatment Based on Disease Extent

• For proctitis (inflammation limited to rectum):

  • Mesalazine 1-g suppository once daily is the preferred initial treatment 1
  • Mesalazine foam or enemas are alternatives, though suppositories deliver medication more effectively to the rectum 1
  • Topical mesalazine is more effective than topical corticosteroids and should be preferred 1, 2

• For left-sided colitis:

  • Combination therapy with mesalazine enema ≥ 1 g/day plus oral mesalazine ≥ 2.4 g/day is recommended 1, 2
  • This combination is more effective than either oral or topical treatments alone 1, 2

• For extensive colitis:

  • Oral mesalazine at doses ≥ 2.4 g/day is the initial approach 1
  • Once-daily dosing is as effective as divided doses and may improve adherence 1, 2

Treatment Escalation Algorithm

1. First-line therapy (Mild to Moderate Disease):

   • Start with combination of topical mesalazine (≥ 1 g/day) plus oral mesalazine (≥ 2.4 g/day) 1, 2
   • The median time to cessation of rectal bleeding is approximately 9 days with high-dose mesalazine (4.8 g/day) compared to 16 days with standard dose (2.4 g/day) 1

2. If no improvement within 10-14 days or symptoms worsen:

   • Consider increasing oral mesalazine dose to 4.8 g/day 1
   • Continue treatment for up to 40 days before determining failure 1

3. If inadequate response to optimized mesalazine therapy:

   • Add oral corticosteroids such as prednisolone 40 mg daily with tapering over 6-8 weeks 1, 2
   • Alternatively, consider budesonide MMX 9 mg/day for left-sided disease as it has fewer systemic side effects 1, 2

4. For severe disease:

   • Hospitalization with intravenous steroids (hydrocortisone 400 mg/day or methylprednisolone 60 mg/day) 3, 2
   • Joint management by gastroenterologist and colorectal surgeon 3, 2
   • Patients should be informed about a 25-30% chance of needing colectomy 3, 2

Important Considerations

• Always exclude infectious causes before attributing symptoms to IBD flare 2
• Single daily dosing of prednisolone is as effective as split-dosing and causes less adrenal suppression 1
• Approximately 50% of patients experience short-term corticosteroid-related adverse events such as acne, edema, sleep and mood disturbance, glucose intolerance and dyspepsia 1
• Long-term steroid use should be avoided due to significant side effects 1, 2
• Regular monitoring of renal function is recommended for patients on long-term 5-ASA therapy, including eGFR before starting, after 2-3 months, and then annually 1

Maintenance Therapy

• After achieving remission, maintenance therapy with mesalazine should be continued to prevent relapse 1, 2
• Lifelong maintenance therapy is generally recommended, especially for those with left-sided or extensive disease 3, 1, 2
• Patients who required two or more courses of corticosteroids in the past year, or who become corticosteroid-dependent or refractory, require treatment escalation with thiopurine, anti-TNF therapy, vedolizumab, or tofacitinib 1

Common Pitfalls to Avoid

• Undertreatment with inadequate mesalazine dosing - efficacy is dose-dependent, with 4.8 g/day being optimal for active disease 4
• Failure to combine topical and oral therapy, which is more effective than either alone 1, 2
• Premature determination of treatment failure - complete remission may take up to 40 days 1
• Rapid tapering of corticosteroids, which is associated with early relapse 3, 2
• Neglecting to monitor renal function in patients on long-term 5-ASA therapy 1