What is the treatment for an acute flare of ulcerative colitis in a patient already on Pentasa (mesalamine)?

From the Guidelines

For an acute flare of ulcerative colitis in a patient already on Pentasa (mesalamine), I recommend a step-up approach starting with optimization of the current mesalamine therapy, ensuring the patient is on an adequate dose of Pentasa (up to 4g daily) and considering adding mesalamine enemas or suppositories for distal disease, as suggested by the AGA clinical practice guidelines 1.

Optimization of Mesalamine Therapy

• Ensure the patient is on an adequate dose of Pentasa (up to 4g daily)
• Consider adding mesalamine enemas or suppositories for distal disease

Addition of Corticosteroids

• If symptoms persist, add oral prednisone at 40mg daily for 1-2 weeks, then taper by 5mg weekly over 8 weeks, as this approach is supported by the British Society of Gastroenterology consensus guidelines 1
• For severe flares unresponsive to oral steroids, hospitalization for IV methylprednisolone (40-60mg daily) may be necessary

Consideration of Immunomodulators or Biologics

• If the patient has frequent flares despite mesalamine, consider adding an immunomodulator like azathioprine (2-2.5mg/kg/day) or 6-mercaptopurine (1-1.5mg/kg/day) for maintenance, or escalate to biologics such as infliximab, adalimumab, or vedolizumab, as suggested by the AGA clinical practice guidelines 1

Supportive Care

• Provide supportive care including hydration, electrolyte replacement, and anti-diarrheals if needed, to address the patient's overall well-being and reduce the risk of complications, as emphasized by the British Society of Gastroenterology consensus guidelines 1

From the FDA Drug Label

INDICATIONS AND USAGE PENTASA is indicated for the induction of remission and for the treatment of patients with mildly to moderately active ulcerative colitis. DOSAGE AND ADMINISTRATION The recommended dosage for the induction of remission and the symptomatic treatment of mildly to moderately active ulcerative colitis is 1g (4 PENTASA 250 mg capsules or 2 PENTASA 500 mg capsules) 4 times a day for a total daily dosage of 4g.

The patient is already on Pentasa, which is indicated for the treatment of mildly to moderately active ulcerative colitis. For an acute flare, the dosage is already at the recommended level for induction of remission and symptomatic treatment.

• The recommended dosage is 1g, 4 times a day, for a total daily dosage of 4g 2 2. No change in dosage is directly recommended by the label for an acute flare.

From the Research

Treatment of Acute Flare of Ulcerative Colitis

• The management of ulcerative colitis (UC) therapy should be guided by the endoscopic extent of inflammation, disease severity, and prognostic factors of poor outcome 3.
• For patients with acute severe UC, corticosteroids remain the first-line therapy, with second-line medical rescue options such as infliximab or cyclosporine considered within 3-5 days of presentation 4.
• Corticosteroids are effective in inducing remission in mild to moderate flares not responding to combined oral and topical mesalazine, but do not represent a therapeutic option as a maintenance treatment due to multiple adverse effects 5.
• Mesalamine is a 5-aminosalicylic acid compound that is the first-line treatment for patients with mild-to-moderate UC, and has been demonstrated to induce both clinical response and remission, and maintain clinical remission 6.
• A randomized controlled trial found that the combination of mesalamine with corticosteroids did not benefit hospitalized patients with acute severe UC more than corticosteroids alone, although there was a numerical reduction in the need for biologics at 90 days in the mesalamine group 7.

Considerations for Patients Already on Pentasa

• Pentasa is a type of mesalamine, and patients already on this medication may require adjustment of their treatment regimen in the event of an acute flare.
• The decision to continue or modify mesalamine therapy should be based on the individual patient's response to treatment and the severity of their disease.
• Corticosteroids may be considered as an addition to mesalamine therapy in patients with acute severe UC, although the benefits and risks of this approach should be carefully weighed 4, 5, 7.