What is the treatment for severe pain in ulcerative colitis?

Treatment of Severe Pain in Ulcerative Colitis

For severe pain in ulcerative colitis, oral corticosteroids such as prednisolone 40 mg daily with gradual tapering over 6-8 weeks is the recommended first-line treatment. 1

Initial Assessment and Management

• Severe pain in ulcerative colitis often indicates moderate to severe disease activity requiring prompt evaluation and aggressive management 1
• Rule out infectious causes of colitis before attributing symptoms to ulcerative colitis flare and escalating therapy 2
• Assess disease severity using clinical parameters (stool frequency, presence of blood, tachycardia, temperature, anemia, elevated inflammatory markers) 1

First-Line Treatment for Severe Pain

• Oral corticosteroids such as prednisolone 40 mg daily is the treatment of choice for moderate to severe ulcerative colitis 1
• Single daily dosing is as effective as split-dosing and causes less adrenal suppression 1
• Taper the dose gradually over 6-8 weeks to prevent early relapse 1
• For patients with distal disease, combination therapy with topical and oral medications is more effective than either treatment alone 3

Hospitalization Criteria

• Patients with systemic symptoms (fever, severe pain, significant anemia) or those generally unwell should be admitted for inpatient management 1
• Intravenous steroids (hydrocortisone 400 mg/day or methylprednisolone 60 mg/day) are appropriate for patients with severe disease requiring hospitalization 1
• Inpatient management should include:
  • Daily physical examination to evaluate abdominal tenderness 1
  • Monitoring of vital signs and stool frequency 1
  • Regular laboratory assessments (CBC, inflammatory markers, electrolytes, albumin) 1
  • Subcutaneous heparin for thromboprophylaxis 1
  • Nutritional support if malnourished 1

Treatment of Refractory Pain

• If no improvement is seen after 2 weeks of oral corticosteroid therapy, consider treatment escalation to biologics or hospital admission 1
• For patients not responding to intravenous steroids within 48-72 hours, second-line therapy should be considered 1
• Options for steroid-refractory disease include:
  • Anti-TNF therapy (infliximab) 1
  • Vedolizumab 1
  • Tofacitinib 1
  • Calcineurin inhibitors (cyclosporine) 4

Surgical Considerations

• If a patient's condition does not improve or deteriorates within 48-72 hours of medical therapy, surgery should be considered 1
• Immediate surgery is recommended in cases of free perforation, life-threatening hemorrhage, or generalized peritonitis 1
• Subtotal colectomy with ileostomy is the surgical treatment of choice for patients with acute severe ulcerative colitis not responding to medical treatment 1

Maintenance Therapy After Pain Control

• Once remission is achieved, maintenance therapy should be initiated to prevent recurrence 1
• Oral 5-ASA is the standard maintenance medical therapy for ulcerative colitis 1
• For patients who required two or more courses of corticosteroids in the past year, or who become corticosteroid-dependent, treatment escalation with thiopurine, anti-TNF therapy, vedolizumab, or tofacitinib is recommended 1
• Lifelong maintenance therapy is generally recommended for all patients, especially those with left-sided or extensive disease 1

Important Considerations and Pitfalls

• Prolonging treatment with high-dose oral corticosteroids has a diminishing chance of achieving remission and increases risk of complications 1
• Rapid steroid tapering is associated with early relapse and should be avoided 3
• Anti-diarrheal medications should be avoided in severe colitis to prevent toxic megacolon 2
• Joint medical and surgical management is essential for the safe management of acute severe colitis 1
• Delay in appropriate surgery when needed can be detrimental to patient outcomes 1