What is the current treatment for a patient with pancolitis likely due to ulcerative colitis?

Treatment of Pancolitis (Ulcerative Colitis)

For mild to moderate pancolitis, start with oral mesalazine 2-4 g daily or balsalazide 6.75 g daily as first-line therapy, and add topical mesalazine 1 g daily for enhanced efficacy and symptomatic relief. 1, 2

Disease Severity Assessment

Before initiating treatment, confirm disease activity by sigmoidoscopy and exclude infection, though treatment should not be delayed while awaiting microbiological results. 1 Use the Truelove and Witts' or Simple Clinical Colitis indices to objectively assess severity. 1

Mild to Moderate Disease

First-Line Therapy

• Oral aminosalicylates are the cornerstone of initial treatment: mesalazine 2-4 g daily or balsalazide 6.75 g daily. 1, 2
• Combination therapy is superior to monotherapy: add topical mesalazine 1 g daily (enemas) to oral therapy for better remission rates. 2, 3
• Once-daily dosing is as effective as divided doses and improves adherence. 2, 3
• Avoid olsalazine in pancolitis due to higher incidence of diarrhea; reserve it for left-sided disease or patients intolerant of other 5-ASA formulations. 1

Treatment Duration and Escalation

• Continue optimized mesalazine therapy for up to 40 days before declaring treatment failure, as sustained remission may take time. 3
• If inadequate response after 10-14 days or symptoms worsen, increase oral mesalazine to 4.8 g daily. 3, 4
• Higher doses (4.8 g/day) achieve faster symptom control with median time to cessation of rectal bleeding of 9 days versus 16 days with standard dosing. 3

Second-Line Therapy

If mesalazine fails after appropriate trial, initiate oral prednisolone 40 mg daily. 1, 2

• Taper prednisolone gradually over 8 weeks according to disease severity and patient response; more rapid reduction increases early relapse risk. 1
• Topical agents (mesalazine or steroids) may be added as adjunctive therapy for troublesome rectal symptoms. 1
• Single daily dosing of prednisolone is as effective as split-dosing and causes less adrenal suppression. 3

Steroid-Dependent or Refractory Disease

Long-term steroid treatment must be avoided due to significant side effects. 1 Approximately 50% of patients experience short-term corticosteroid-related adverse events including acne, edema, sleep and mood disturbance, glucose intolerance, and dyspepsia. 3

For patients requiring two or more steroid courses in the past year or who become steroid-dependent, initiate immunomodulators: 2, 3

• Azathioprine 1.5-2.5 mg/kg/day, or 1
• Mercaptopurine 0.75-1.5 mg/kg/day 1

Severe Pancolitis

Patients meeting Truelove and Witts' criteria (bloody stool frequency ≥6/day plus tachycardia >90/min, temperature >37.8°C, hemoglobin <10.5 g/dL, or ESR >30 mm/h) require immediate hospital admission for intensive intravenous therapy. 1, 2, 5

Inpatient Management Protocol

Joint management by gastroenterologist and colorectal surgeon is mandatory. 1, 2 Patients should be informed of a 25-30% chance of needing colectomy. 1

Monitoring requirements: 1, 2

• Daily physical examination for abdominal tenderness and rebound
• Vital signs four times daily (more frequently if deteriorating)
• Stool chart recording frequency, character, and presence of blood
• Laboratory tests every 24-48 hours: CBC, CRP/ESR, electrolytes, albumin, liver function
• Daily abdominal radiography if colonic dilatation detected (transverse colon diameter >5.5 cm); otherwise maintain low threshold for imaging if clinical deterioration occurs

Supportive care: 1, 2

• Intravenous fluid and electrolyte replacement to correct dehydration
• Blood transfusion to maintain hemoglobin >10 g/dL
• Subcutaneous heparin to reduce thromboembolism risk
• Nutritional support (enteral or parenteral) if malnourished

Medical therapy for severe disease: 1

• Intravenous corticosteroids (hydrocortisone 400 mg/day or methylprednisolone 60 mg/day) 5
• Ciclosporin may be effective for severe steroid-refractory colitis 1
• Infliximab 5 mg/kg intravenously at 0,2, and 6 weeks has been shown effective for moderately to severely active ulcerative colitis with inadequate response to conventional therapy 6, 7, 8

Maintenance Therapy

Lifelong maintenance therapy is generally recommended for all patients with pancolitis. 1, 2

• Aminosalicylates are effective and safe for long-term maintenance. 2
• Mesalazine 2.4 g/day is the optimal maintenance dosage. 4
• Maintenance therapy may reduce colorectal cancer risk. 1
• Regular monitoring of renal function is required: eGFR before starting, after 2-3 months, then annually. 3

Critical Pitfalls to Avoid

Do not use sulfasalazine 2-4 g daily as first-line therapy due to higher incidence of side effects compared to newer 5-ASA drugs; reserve for selected patients with reactive arthropathy. 1, 5

Treat proximal constipation with stool bulking agents or laxatives, as this can complicate extensive colitis. 1, 5

Avoid antidiarrheal medications as they can mask worsening symptoms while allowing underlying inflammation to progress and may predispose to toxic dilatation. 2

Screen for tuberculosis before initiating anti-TNF therapy and treat latent infection prior to use. 6

Ensure appropriate vaccination schedules before starting immunosuppression. 2