What are the guidelines for managing ulcerative colitis?

Management of Ulcerative Colitis

First-Line Therapy for Mild-to-Moderate Disease

For patients with extensive mild-to-moderate ulcerative colitis, initiate standard-dose mesalamine 2-3 grams/day combined with rectal mesalamine as first-line therapy. 1, 2, 3

• Standard-dose mesalamine (2-3 grams/day) or diazo-bonded 5-ASA is superior to low-dose mesalamine, sulfasalazine, or no treatment for extensive disease 1, 2
• Adding rectal mesalamine to oral 5-ASA significantly improves remission rates compared to oral therapy alone 1, 2, 3
• Once-daily dosing of oral mesalamine is preferred over multiple daily doses to improve adherence 1, 2
• Mesalamine is FDA-approved for induction and maintenance of remission in adults with mildly to moderately active ulcerative colitis 4

Disease Location-Specific Approach

For proctitis: Use mesalamine 1-gram suppository once daily as the preferred initial treatment, as it delivers medication more effectively to the rectum 2

For proctosigmoiditis or left-sided disease: Combine topical mesalamine enema ≥1 gram/day with oral mesalamine ≥2.4 grams/day, which is more effective than monotherapy 1, 2

Escalation for Suboptimal Response

• If standard-dose therapy fails or moderate disease activity persists, escalate to high-dose mesalamine (>3 grams/day) combined with rectal mesalamine 1, 2, 3
• Monitor response closely: if symptoms deteriorate, rectal bleeding persists beyond 10-14 days, or sustained relief is not achieved after 40 days of appropriate 5-ASA therapy, escalate treatment 2

Moderate-to-Severe Disease Management

For moderate-to-severe ulcerative colitis, use oral prednisolone 40 mg daily for induction, then transition to maintenance therapy with biologics (infliximab or vedolizumab preferred) with or without immunomodulators. 2, 3, 5

• Oral corticosteroids (prednisolone 40 mg daily) are appropriate for induction of remission in moderate-to-severe disease 2, 3
• After successful corticosteroid induction, transition to maintenance with 5-ASA, thiopurines, anti-TNF agents (with or without thiopurine/methotrexate), or vedolizumab 2, 3
• For corticosteroid-resistant or corticosteroid-dependent disease, initiate anti-TNF therapy or vedolizumab 2
• Infliximab and vedolizumab are the preferred first-line biologics in biologic-naïve patients 3
• Combination therapy (biologic plus immunomodulator) is more effective than monotherapy 3
• Infliximab is FDA-approved for reducing signs and symptoms, inducing and maintaining clinical remission and mucosal healing, and eliminating corticosteroid use in adults with moderately to severely active ulcerative colitis who have had inadequate response to conventional therapy 5

Acute Severe Ulcerative Colitis (Hospitalized Patients)

Acute severe ulcerative colitis requires joint management by a gastroenterologist and colorectal surgeon from the outset, with intravenous methylprednisolone 40-60 mg/day (or hydrocortisone 400 mg/day) as the mainstay of treatment. 2, 3, 6

• Perform daily physical examination to evaluate for abdominal tenderness and rebound tenderness 2, 3
• Provide intravenous fluid and electrolyte replacement 2, 3
• Maintain hemoglobin >10 g/dL 2, 3
• Administer subcutaneous heparin to reduce thromboembolism risk 2, 3, 6
• For patients refractory to IV corticosteroids after 3-5 days, consider infliximab or cyclosporine as rescue therapy 2, 6
• Critical pitfall: Never continue IV corticosteroids beyond 7-10 days without escalating to rescue therapy or surgery 6
• Emergency surgery is indicated for hemodynamic instability, free perforation, toxic megacolon, or massive hemorrhage 6

Maintenance Therapy

Lifelong maintenance therapy is recommended for all patients, especially those with left-sided or extensive disease, to reduce relapse risk and potentially reduce colorectal cancer risk. 2, 3

• Maintenance options include 5-ASA, thiopurines, anti-TNF agents, or vedolizumab depending on disease severity and prior response 2, 3
• Patients in remission on biologics and/or immunomodulators after prior 5-ASA failure may discontinue 5-aminosalicylates 2, 3
• For patients with distal disease who relapse more than once yearly, lifelong maintenance is particularly important 3

Special Considerations and Common Pitfalls

• Sulfasalazine alternative: Patients already on sulfasalazine in remission or with prominent arthritic symptoms may continue sulfasalazine 2-4 grams/day if alternatives are cost-prohibitive, despite higher intolerance rates 1, 2
• Not recommended: Probiotics, curcumin, and fecal microbiota transplantation are not recommended for routine use due to insufficient evidence, and their use risks delaying proven effective therapy 1, 2
• Never use anti-diarrheal medications in severe colitis as they increase the risk of toxic megacolon 6
• Never delay corticosteroids while awaiting stool cultures in suspected severe ulcerative colitis 6
• Exclude infectious causes (particularly C. difficile and cytomegalovirus) before escalating immunosuppression 6