What is the treatment for severe ulcerative colitis?

Treatment of Severe Ulcerative Colitis

Intravenous corticosteroids (methylprednisolone 40-60 mg/day or hydrocortisone 100 mg four times daily) are the first-line treatment for hospitalized patients with acute severe ulcerative colitis, and patients who fail to respond after 3-5 days should receive rescue therapy with either infliximab or cyclosporine. 1

Initial Management and Supportive Care

All patients with severe ulcerative colitis require hospitalization with immediate supportive measures:

• Intravenous fluid and electrolyte replacement with potassium supplementation of at least 60 mmol/day, as hypokalaemia or hypomagnesaemia can precipitate toxic dilatation 1
• Subcutaneous low-molecular-weight heparin for thromboprophylaxis, as thromboembolism risk is significantly elevated during disease flares 1
• Blood transfusion to maintain hemoglobin above 8-10 g/dL 1
• Nutritional support if malnourished, preferring enteral over parenteral nutrition (9% vs 35% complication rate) 1

Diagnostic Workup Before Treatment

Before initiating therapy, perform these essential investigations:

• Unprepared flexible sigmoidoscopy with biopsy to confirm diagnosis and exclude cytomegalovirus infection, which causes steroid-refractory disease 1
• Stool cultures and Clostridium difficile toxin assay, as C. difficile is more prevalent in severe UC and increases mortality; if detected, administer oral vancomycin and consider stopping immunosuppression 1
• Exclude other infectious etiologies before escalating immunosuppressive therapy 1

First-Line Corticosteroid Therapy

Intravenous methylprednisolone 60 mg every 24 hours or hydrocortisone 100 mg four times daily should be administered; higher doses are no more effective, and lower doses are less effective 1. Bolus injection is as effective as continuous infusion 1. Treatment should be given for a defined period, as extending therapy beyond 7-10 days carries no additional benefit 1.

Alternative to Steroids

Intravenous ciclosporin 2 mg/kg/day monotherapy is an alternative first-line option for patients who should avoid steroids (steroid psychosis susceptibility, severe osteoporosis, or poorly controlled diabetes) 1

Rescue Therapy for Steroid-Refractory Disease

Critical timing: Patients who do not respond to intravenous corticosteroids by Day 3-5 require rescue therapy 1. Delaying this decision results in high morbidity from prolonged ineffective steroid exposure 1.

Rescue Options (Equivalent Efficacy)

• Infliximab 5 mg/kg given as intravenous induction at 0,2, and 6 weeks 1, 2
• Cyclosporine 2 mg/kg/day intravenously 1

Important: No recommendation can be made regarding intensive versus standard infliximab dosing in this setting 1. Both infliximab and cyclosporine have equivalent efficacy for rescue therapy 1.

Medications to Avoid

Withdraw these medications immediately as they risk precipitating colonic dilatation:

• Anticholinergic agents 1
• Anti-diarrheal medications 1
• Non-steroidal anti-inflammatory drugs 1
• Opioid drugs 1

Antibiotic Use

Routine adjunctive antibiotics are NOT recommended in patients without documented infections 1. Antibiotics should only be used if infection is suspected (first attack of short duration, recent hospitalization, travel to endemic areas) or immediately prior to surgery 1.

Multidisciplinary Approach

Joint care by gastroenterologist and colorectal surgeon is essential from admission 1. Early surgical consultation prevents delayed colectomy in patients who will ultimately require surgery 1.

Indications for Emergency Surgery

• Refractory toxic megacolon 3
• Perforation 3
• Continuous severe colorectal bleeding 3
• Failure of medical therapy including rescue agents 1

Monitoring and Predictive Factors

Close monitoring of symptoms, serum C-reactive protein, and albumin levels guides decision-making for rescue therapy 4. Mortality with second-line medical therapy (infliximab or cyclosporine) is not increased compared to early colectomy, though mortality is higher in patients over 60 years and those with comorbidities 1.

Critical Pitfalls to Avoid

• Do not extend intravenous corticosteroids beyond 7-10 days without initiating rescue therapy, as this increases morbidity without benefit 1
• Do not delay rescue therapy decision beyond Day 3-5 of steroid treatment 1
• Do not use routine antibiotics without documented infection 1
• Do not continue ineffective medical therapy when surgery is indicated, as delayed colectomy worsens outcomes 1