What is the recommended initial hospital treatment for an ulcerative colitis (UC) flare?

Initial Hospital Treatment of Ulcerative Colitis Flare

Intravenous corticosteroids at a dose equivalent to 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, with response assessed at day 3-5 to determine need for rescue therapy. 1

First-Line Corticosteroid Therapy

• Initiate IV methylprednisolone 40-60 mg/day or hydrocortisone 100 mg four times daily immediately upon admission for acute severe UC (defined as ≥6 bloody stools/day plus fever >37.8°C, tachycardia >90 bpm, hemoglobin <105 g/L, or CRP >30 mg/L). 1, 2

• Higher doses of IV corticosteroids (>60 mg methylprednisolone equivalent) provide no additional benefit and increase adverse effects without reducing colectomy rates. 1, 2

• Single daily dosing is as effective as split-dosing or continuous infusion and causes less adrenal suppression. 1

• Approximately 67% of patients respond to IV corticosteroids alone, avoiding need for rescue therapy. 3

Critical Supportive Measures

• Start low-molecular-weight heparin thromboprophylaxis immediately—rectal bleeding is NOT a contraindication, as ASUC carries significant thromboembolism risk. 3, 2

• Provide IV fluid and electrolyte replacement with potassium supplementation of at least 60 mmol/day to prevent hypokalemia and toxic megacolon. 3, 2

• Maintain hemoglobin >10 g/dL with blood transfusion if needed. 2

• Discontinue all opioids, NSAIDs, antidiarrheals, and anticholinergic medications as these increase toxic megacolon risk. 2

• Provide nutritional support (enteral preferred) if patient is malnourished. 2

Infection Exclusion

• Obtain stool studies for bacterial pathogens and Clostridium difficile before initiating treatment. 2

• Perform flexible sigmoidoscopy with biopsies to assess severity and exclude cytomegalovirus infection. 2

• Do NOT use adjunctive antibiotics routinely in patients without documented gastrointestinal or extraintestinal infections—four RCTs show no benefit. 1

Response Assessment and Treatment Duration

• Assess clinical and biochemical response after 3-5 days of IV corticosteroids by monitoring stool frequency, vital signs, CRP, albumin, and complete blood count daily. 1, 3, 2

• Limit IV corticosteroid treatment to maximum 7-10 days—prolonged courses beyond this offer no additional benefit and increase toxicity and surgical complications. 1, 3, 2

• Patients not responding by day 3-5 require escalation to rescue therapy or colectomy. 3, 2

Rescue Therapy for Corticosteroid-Refractory Disease

If inadequate response after 3-5 days of IV corticosteroids:

• Infliximab 5 mg/kg IV (at weeks 0,2, and 6) OR cyclosporine 2 mg/kg/day IV are equally effective rescue options. 2, 4

• Both agents achieve 65-85% initial response rates, though only 50% of responders avoid colectomy at 5 years. 4

• Assess response to rescue therapy within 5-7 days—non-responders should proceed to colectomy to prevent life-threatening complications. 2, 4

• Both rescue agents are immunosuppressants used with steroids and azathioprine, carrying risk of serious opportunistic infections requiring close monitoring. 4

Surgical Considerations

• Approximately 20-29% of ASUC patients require colectomy during the same admission. 3

• Emergency colectomy is indicated for: refractory toxic megacolon, colonic perforation, severe colorectal bleeding, or failure of rescue therapy after 4-7 days. 2, 5

• Overall ASUC mortality is 1%, but significantly higher in patients >60 years or with comorbidities. 3

• Early surgical consultation should occur at admission, as joint gastroenterology-surgery management improves outcomes. 2

Common Pitfalls to Avoid

• Do not continue IV corticosteroids beyond 7 days in non-responders—this increases surgical complications without improving outcomes. 1, 3

• Do not use higher corticosteroid doses (>60 mg methylprednisolone equivalent) as meta-regression shows no correlation with reduced colectomy rates. 1

• Do not delay rescue therapy or surgery in patients failing to improve by day 3-5, as this increases mortality risk. 3, 2

• Approximately 50% of patients experience short-term corticosteroid adverse effects including acne, edema, sleep/mood disturbance, glucose intolerance, and dyspepsia. 1