What are the ways to manage disease flare-ups in ulcerative colitis?

Managing Ulcerative Colitis Flare-Ups

For moderate to severe UC flares with frequent rectal bleeding and significantly increased stool frequency, use fecal calprotectin >150 mg/g or elevated CRP to confirm active inflammation and initiate treatment adjustment without routine endoscopy, then escalate to intravenous corticosteroids (hydrocortisone 400 mg/day or methylprednisolone 60 mg/day) as first-line therapy, with infliximab or cyclosporine as rescue therapy if no response after 3-5 days. 1, 2

Severity Assessment and Initial Approach

Moderate to Severe Flares

• Use biomarkers to guide treatment decisions: In patients with moderate to severe symptoms (frequent rectal bleeding, significantly increased stool frequency), fecal calprotectin >150 mg/g, elevated fecal lactoferrin, or elevated CRP reliably indicate moderate to severe endoscopic inflammation and can inform treatment adjustment without requiring endoscopic assessment. 1
• Hospitalize immediately for severe flares requiring joint management by gastroenterology and colorectal surgery. 1, 3
• Monitor vital signs four times daily with stool charts documenting number, character, and presence of blood. 1
• Obtain laboratory studies every 24-48 hours including CBC, ESR or CRP, electrolytes, albumin, and liver function tests. 1

Mild Flares

• For mild symptoms with elevated biomarkers (fecal calprotectin >150 mg/g, elevated fecal lactoferrin, or elevated CRP), perform endoscopic assessment rather than empiric treatment adjustment. 1
• Exception: If the patient recently underwent treatment adjustment for moderate to severe flare and now has mild residual symptoms, elevated biomarkers may be used to inform dose adjustments without endoscopy. 1

Medical Management Algorithm

First-Line Therapy for Severe Flares

• Intravenous corticosteroids: Hydrocortisone 400 mg/day or methylprednisolone 60 mg/day. 1
• Supportive care:
  • IV fluid and electrolyte replacement to maintain hemoglobin >10 g/dl with blood transfusion if needed. 1
  • Subcutaneous heparin for thromboprophylaxis. 1
  • Nutritional support (enteral or parenteral) if malnourished. 1
  • Daily abdominal radiography if colonic dilatation (transverse colon >5.5 cm) detected. 1

Rescue Therapy (After 3-5 Days Without Response)

• Infliximab or cyclosporine are indicated when patients fail to respond adequately to IV corticosteroids after 3-5 days. 2, 4
• Infliximab dosing: 5 mg/kg at weeks 0,2, and 6, then every 8 weeks. 5
• Close monitoring required: Track symptoms, serum CRP, and albumin levels during rescue therapy. 2

Mild to Moderate Flares (Outpatient)

• Combination therapy is superior: Topical mesalazine ≥1 g/day PLUS oral mesalazine ≥2.4 g/day is more effective than either alone. 3
• Oral prednisolone 40 mg daily when prompt response needed or mesalazine unsuccessful, tapered gradually over 8 weeks (rapid reduction causes early relapse). 1, 3
• Once-daily dosing of mesalazine is as effective as divided doses and improves adherence. 3

Critical Pitfalls and Caveats

Exclude Infections First

• Always rule out infectious causes before attributing symptoms to IBD flare, as superimposed bacterial or viral infections account for significant proportion of flares. 1, 3, 2
• Stool cultures are positive in only 40-60% of infectious colitis cases, so negative cultures don't exclude infection. 1

When to Proceed to Colectomy

• Urgent colectomy indicated if medical rescue therapy fails or in fulminant colitis to prevent critical complications. 2, 4
• Inform patients of 25-30% chance of needing colectomy during severe flare. 1, 3
• Presence of extensive and deep ulcerations at endoscopy increases colectomy risk. 1

Biomarker Interpretation Nuances

• In high pretest probability scenarios (typical UC symptoms with frequent bleeding), fecal calprotectin >150 mg/g has only 4.6% false positive rate for moderate to severe inflammation. 1
• Normal biomarkers don't exclude inflammation in patients with moderate to severe symptoms—endoscopic assessment may still be needed. 1
• In mild symptoms, biomarkers may not reliably indicate moderate to severe inflammation, warranting endoscopic confirmation. 1

Long-Term Considerations

• Half of patients with acute severe UC require colectomy within 5 years despite initial medical management. 4
• Maintenance therapy with aminosalicylates, azathioprine, or mercaptopurine should be initiated after achieving remission to reduce relapse risk. 1, 3