What is the management approach for a patient experiencing an ulcerative colitis flare?

Management of Ulcerative Colitis Flare

For patients with moderate to severe UC flare symptoms (frequent rectal bleeding and significantly increased stool frequency), use fecal calprotectin >150 mg/g, elevated fecal lactoferrin, or elevated CRP to confirm active inflammation and initiate treatment adjustment without requiring endoscopy. 1

Initial Assessment and Severity Stratification

Rule Out Infectious Causes First

• Always exclude infectious causes before attributing symptoms to UC flare, as superimposed bacterial or viral infections account for a significant proportion of flares 2
• Obtain stool cultures for bacterial pathogens, Clostridium difficile toxin, and consider viral testing 2
• Treatment should not be delayed awaiting stool culture results in severe presentations 3

Biomarker-Guided Assessment

• In patients with moderate to severe symptoms, fecal calprotectin >150 mg/g, elevated fecal lactoferrin, or elevated CRP reliably indicate moderate to severe endoscopic inflammation and can guide treatment decisions without routine endoscopy 1, 2
• In patients with only mild symptoms (infrequent rectal bleeding or mildly increased stool frequency), elevated biomarkers should prompt endoscopic assessment rather than empiric treatment escalation 1
• Obtain complete blood count, inflammatory markers (CRP, ESR), electrolytes, albumin, and liver function tests 2, 3

Treatment Algorithm by Severity

Mild to Moderate Flare (Outpatient Management)

• First-line therapy: Combination topical mesalazine 1g daily PLUS oral mesalazine 2-4g daily, which achieves superior remission rates compared to monotherapy 4, 3
• Once-daily dosing of topical mesalazine is preferred over multiple daily doses 4
• For patients intolerant to topical mesalazine, use topical corticosteroids as second-line therapy 4, 3
• If inadequate response to first-line therapy, add oral prednisolone 40mg daily, tapered over 8 weeks 4, 3

Moderate to Severe Flare (Consider Advanced Therapy)

• For biologic-naïve patients, initiate advanced therapy with infliximab, risankizumab, guselkumab, or ozanimod as first-line agents, as these demonstrate superior efficacy for inducing clinical remission compared to adalimumab 4
• Combine TNF antagonists with thiopurines or methotrexate rather than using biologic monotherapy, as combination therapy is superior for inducing remission 4, 3
• Infliximab dosing: 5 mg/kg IV at weeks 0,2, and 6, then every 8 weeks 5
• Some patients who initially respond may benefit from dose escalation to 10 mg/kg if they later lose response 5

Severe/Acute Severe Flare (Hospitalization Required)

Immediate hospitalization is mandatory for severe flares, defined as ≥6 bloody stools daily with fever, tachycardia, anemia, and elevated ESR 3

Initial Management (Days 1-3)

• Intravenous corticosteroids are first-line therapy: hydrocortisone 100 mg four times daily OR methylprednisolone 60 mg/day 4, 2, 3
• Methylprednisolone is preferred due to less mineralocorticoid effect and lower risk of hypokalemia 4
• Provide supportive care: IV fluid and electrolyte replacement with potassium supplementation of at least 60 mmol/day 4, 2
• Administer subcutaneous low-molecular-weight heparin for thromboprophylaxis (rectal bleeding is NOT a contraindication) 4, 2
• Monitor vital signs four times daily and obtain laboratory studies (CBC, CRP, electrolytes, albumin) every 24-48 hours 2, 3
• Obtain daily abdominal radiography to monitor for toxic megacolon 3
• Avoid anti-diarrheal medications to prevent toxic megacolon 4

Response Assessment (Day 3-5)

• Approximately 67% of patients respond to IV corticosteroids alone 4
• If inadequate response by day 3-5, initiate rescue therapy with infliximab 5 mg/kg OR cyclosporine 2 mg/kg/day 4, 2, 3
• Treatment duration with IV corticosteroids should be limited to 7-10 days maximum, as prolonged courses carry no additional benefit and increase toxicity 4

Surgical Considerations

• Urgent colectomy is indicated if medical rescue therapy fails after 4-7 days or in fulminant colitis 2, 6
• Approximately 20-29% of acute severe UC patients require colectomy during the same admission 4
• Emergency surgery should not be seen as a last resort but as a life-saving procedure, with overall mortality of acute severe UC at 1% (higher in patients >60 years or with comorbidities) 4, 6
• The preferred surgical approach is subtotal colectomy with ileostomy and preservation of the rectum 6

Critical Pitfalls and Caveats

Common Mistakes to Avoid

• Do not switch between different oral 5-ASA formulations if initial therapy fails, as this is ineffective 4
• Never use higher doses of IV corticosteroids than recommended, as they offer no additional benefit and increase adverse events 4
• Do not prolong IV corticosteroid therapy beyond 7-10 days, as this increases toxicity without improving outcomes 4
• Avoid delaying surgical consultation in severe cases, as prolonged observation increases risk of toxic megacolon and perforation with very high mortality 2, 6

Special Monitoring Considerations

• In patients with normal biomarkers but typical UC symptoms, endoscopic assessment may be preferred, as normal biomarkers do not exclude moderate to severe inflammation 1
• Joint management by gastroenterology and colorectal surgery is essential for hospitalized patients with severe flares 2, 3

Maintenance After Flare Resolution

• Lifelong maintenance therapy is recommended with aminosalicylates, thiopurines, or biologics to reduce relapse risk and potentially reduce colorectal cancer risk 4, 3
• For patients achieving corticosteroid-free remission on combination therapy (TNF antagonist + immunomodulator) for ≥6 months, do not withdraw the TNF antagonist 4