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 Hospitalization and Supportive Care

Upon admission, immediate supportive measures are critical:

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

Mandatory Diagnostic Workup Before Treatment Escalation

Before initiating or escalating immunosuppressive therapy:

• Perform unprepared flexible sigmoidoscopy with biopsy to confirm diagnosis and exclude cytomegalovirus infection, which causes steroid-refractory disease 1
• Obtain 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 all infectious etiologies before escalating immunosuppressive therapy 1

First-Line Corticosteroid Therapy

• Administer intravenous methylprednisolone 60 mg every 24 hours or hydrocortisone 100 mg four times daily 1, 2
• Higher doses are no more effective, and lower doses are less effective 1
• Treatment should be given for a defined period of 7-10 days maximum, as extending therapy beyond this carries no additional benefit 1

Rescue Therapy Decision Point (Day 3-5)

Patients who do not respond to intravenous corticosteroids by Day 3-5 require rescue therapy. 1, 3, 4 This is a critical decision point that should not be delayed.

Choice Between Infliximab and Cyclosporine

Both agents have equivalent efficacy for rescue therapy 1, but selection depends on specific clinical factors:

Infliximab 5 mg/kg intravenously at 0,2, and 6 weeks is preferred when:

• Patient has already been exposed to immunosuppressives 5
• Maintenance therapy option is desired 5
• Better short-term safety profile is prioritized 5
• Patient is biologic-naïve 2

Cyclosporine 2 mg/kg/day intravenously is preferred when:

• Rapid onset of action is critical with imminent risk of colectomy 5
• Short half-life is advantageous 5
• Patient requires quick assessment of response 1

Medications to Immediately Discontinue

Withdraw anticholinergic agents, anti-diarrheal medications, non-steroidal anti-inflammatory drugs, and opioid drugs immediately, as they risk precipitating colonic dilatation 1

Antibiotic Use: When NOT to Use Them

Routine adjunctive antibiotics are NOT recommended in patients without documented infections 1. Antibiotics should only be used if infection is suspected or immediately prior to surgery 1. This is a common pitfall—do not reflexively add antibiotics.

Mandatory Multidisciplinary Approach

Joint care by gastroenterologist and colorectal surgeon is essential from admission 1, 2. Early surgical consultation prevents delayed colectomy in patients who will ultimately require surgery 1. Daily physical examination for abdominal tenderness and rebound is required 2.

Critical Timing 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, 3, 4
• Do not continue ineffective medical therapy when surgery is indicated, as delayed colectomy worsens outcomes 1
• Do not use routine antibiotics without documented infection 1

Surgical Indications

Emergency colectomy is indicated for:

• Refractory toxic megacolon 6
• Perforation 6
• Continuous severe colorectal bleeding 6
• Failure of medical rescue therapy 1

Timely colectomy should be performed to prevent critical complications if medical therapy fails 3. Even when cyclosporine or infliximab postpone colectomy in at least half of patients, elective colectomy at a later stage may offer better outcomes 5.