Treatment of Ulcerative Colitis Flare-Up
Treatment of UC flares is stratified by severity: mild-to-moderate disease requires oral and rectal 5-ASA as first-line therapy, moderate-to-severe disease requires oral corticosteroids with transition to maintenance therapy, and severe flares requiring hospitalization demand IV corticosteroids with rescue therapy (infliximab or cyclosporine) if no response within 3-5 days. 1
Severity Assessment Before Treatment
Use biomarkers to guide treatment decisions rather than symptoms alone:
- In patients with moderate-to-severe symptoms (frequent rectal bleeding, significantly increased stool frequency), use fecal calprotectin >150 mg/g, elevated fecal lactoferrin, or elevated CRP to confirm active inflammation and initiate treatment without requiring endoscopy 1, 2
- These biomarkers have only a 4.6% false positive rate when fecal calprotectin >150 mg/g is used in symptomatic patients 3
- Always exclude infection first - obtain stool cultures for bacterial pathogens and C. difficile toxin testing before attributing symptoms to UC flare, as superimposed infections account for a significant proportion of flares 2, 3
Treatment Algorithm by Disease Severity
Mild-to-Moderate UC Flare
First-line therapy:
- Oral 5-ASA at 4.8 g/day of the active moiety (not lower doses) combined with rectal 5-ASA for distal disease 1, 4
- Topical 5-ASA is more effective than oral therapy alone for distal disease 5
If inadequate response:
- Add oral corticosteroids (prednisone 40-60 mg/day) 1
Moderate-to-Severe UC Flare (Outpatient)
Induction therapy:
- Oral corticosteroids (prednisone 40-60 mg/day or equivalent) 1
Transition to maintenance therapy after achieving symptomatic remission:
- Options include: 5-ASA, thiopurine, anti-TNF therapy (with or without thiopurine/methotrexate), or vedolizumab 1
- Do not continue corticosteroids for maintenance - the goal is complete remission without corticosteroid therapy 1
Severe UC Flare (Hospitalized)
Immediate management:
- IV corticosteroids: hydrocortisone 400 mg/day or methylprednisolone 60 mg/day 2, 6
- IV fluid and electrolyte replacement 2
- Subcutaneous heparin for thromboprophylaxis 2
- Monitor vital signs four times daily with stool charts documenting frequency, character, and blood 2
- Obtain labs every 24-48 hours: CBC, ESR or CRP, electrolytes, albumin, liver function tests 2
Rescue therapy if inadequate response after 3-5 days:
- Infliximab 5 mg/kg IV at 0,2, and 6 weeks, then every 8 weeks 2, 7, 6
- Alternative: cyclosporine IV (then transition to oral with azathioprine/6-mercaptopurine) 2, 5
Surgical consultation:
- Joint management by gastroenterology and colorectal surgery is mandatory for severe flares 2
- Urgent colectomy indicated if medical rescue therapy fails, with 25-30% of severe flares requiring colectomy 2
Corticosteroid-Resistant or Dependent Disease
For patients who fail corticosteroids or become dependent:
- Anti-TNF therapy (infliximab, adalimumab, golimumab) or vedolizumab is recommended 1
- Infliximab dosing: 5 mg/kg at 0,2, and 6 weeks, then every 8 weeks 7
- Some patients may benefit from dose escalation to 10 mg/kg if they lose response 1, 7
Critical Pitfalls to Avoid
Infection exclusion:
- Stool cultures are positive in only 40-60% of infectious colitis cases, so negative cultures do not exclude infection 2
- Test for cytomegalovirus in treatment-refractory or severe cases 3
- Discontinue or adjust immunosuppressive medications during active infection 3
Biomarker limitations:
- Normal biomarkers (fecal calprotectin <150 mg/g) do not exclude moderate-to-severe inflammation in symptomatic patients - false negative rate is 24.7% 3
- Clinical judgment supersedes normal biomarkers when symptoms are convincing 3
Timing of treatment escalation: