What is the recommended treatment for a patient with gastrointestinal inflammation?

Treatment of Gastrointestinal Inflammation

For inflammatory bowel disease, initiate treatment based on disease type and severity: ulcerative colitis requires topical and/or oral mesalamine for mild-moderate disease or prednisolone 40 mg daily for moderate-severe disease, while Crohn's disease requires high-dose mesalazine (4 g/day) for mild ileocolonic disease or prednisolone 40 mg daily for moderate-severe disease. 1

Ulcerative Colitis Treatment Algorithm

Distal Disease (Proctitis)

• Start with topical mesalamine as first-line therapy for ulcerative proctitis 1
• If inadequate response or intolerance, add oral mesalamine or substitute with topical corticosteroids 1
• For refractory proctitis, escalate to oral corticosteroids, topical tacrolimus, JAK inhibitors, S1P agonists, or biologic therapy 1

Mild to Moderate Extensive Disease

• Initiate oral mesalamine combined with topical mesalamine for disease extending beyond the rectum 1
• Use doses >2.4 g/day for optimal efficacy, as lower doses are ineffective 2, 3
• High-dose mesalamine (4.8 g/day) achieves 43% clinical remission at 6 weeks versus 35% with 2.4 g/day 3
• If no response within 2-4 weeks, initiate oral corticosteroids 1

Moderate to Severe Disease

• Start prednisolone 40 mg daily combined with mesalamine 1
• Taper prednisolone gradually over 8 weeks according to severity and patient response—rapid reduction causes early relapse 1, 4
• If no adequate response to oral corticosteroids within 2 weeks, or if corticosteroid taper is unsuccessful, initiate advanced therapy (biologics or small molecule drugs) 1

Severe Disease Requiring Hospitalization

• Admit patients meeting Truelove and Witts' criteria or those failing maximal oral therapy 1
• Administer intravenous hydrocortisone 400 mg/day or methylprednisolone 60 mg/day 1
• Provide subcutaneous heparin to reduce thromboembolism risk 1
• Monitor daily with vital signs, stool charts, FBC, CRP, and abdominal radiography if colonic dilatation present 1
• Maintain joint medical and surgical management with early colorectal surgery consultation 1

Maintenance Therapy

• Continue lifelong maintenance therapy with aminosalicylates for all patients, especially those with left-sided or extensive disease 1
• Alternative maintenance options include azathioprine or mercaptopurine 1

Crohn's Disease Treatment Algorithm

Mild Ileocolonic Disease

• Initiate high-dose mesalazine 4 g/daily as sufficient initial therapy 1, 4
• Consider patient preferences when selecting therapy to improve adherence 4

Moderate to Severe Disease

• Start prednisolone 40 mg daily for moderate-severe disease or mild-moderate disease failing mesalazine 1, 4
• Taper prednisolone gradually over 8 weeks—more rapid reduction causes early relapse 1, 4
• For isolated ileo-caecal disease with moderate activity, budesonide 9 mg daily is appropriate but marginally less effective than prednisolone 1

Alternative Induction Options

• Elemental or polymeric diets are less effective than corticosteroids but may be used in patients with contraindications to steroids or those preferring to avoid them 1, 4
• Metronidazole 10-20 mg/kg/day is effective but not first-line due to side effects; reserve for colonic or treatment-resistant disease 1

Severe Disease

• Administer intravenous hydrocortisone 400 mg/day or methylprednisolone 60 mg/day 1
• Add concomitant intravenous metronidazole as it may be difficult to distinguish active disease from septic complications 1

Fistulating and Perianal Disease

• Use metronidazole 400 mg three times daily and/or ciprofloxacin for active perianal disease 1
• Infliximab 5 mg/kg is effective for persistent or complex fistulae in combination with medical treatment 1
• Consider surgery for persistent or complex fistulae combined with medical treatment 1

Maintenance of Remission

• All smokers must be strongly advised to stop—smoking cessation is the most important factor in maintaining remission 1
• Azathioprine 1.5-2.5 mg/kg/day or mercaptopurine 0.75-1.5 mg/kg are effective but reserved as second-line therapy due to potential toxicity 1
• Methotrexate 15-25 mg IM weekly is effective for patients whose active disease responded to IM methotrexate 1
• Infliximab 5-10 mg/kg every 8 weeks is effective for up to 44 weeks in patients who responded to initial infusion 1, 5
• Mesalazine has limited benefit and is ineffective at doses <2 g/day or for those needing steroids for induction 1

Steroid-Dependent or Refractory Disease

• Define steroid-refractory as active disease despite prednisolone >20 mg/day for >2 weeks 1
• Define steroid-dependent as relapse when reducing below 20 mg/day or within 6 weeks of stopping 1
• Use azathioprine 1.5-2.5 mg/kg/day or mercaptopurine 0.75-1.25 mg/kg/day as first-line agents 1
• Infliximab 5 mg/kg should be reserved for patients refractory to or intolerant of steroids, mesalazine, azathioprine/mercaptopurine, and methotrexate, where surgery is inappropriate 1

Surgery Considerations

• Consider surgery for patients failing medical therapy 1, 4
• Surgery may be appropriate as primary therapy in patients with limited ileal or ileo-caecal disease 1

Critical Pitfalls to Avoid

• Never taper corticosteroids rapidly—this consistently causes early relapse 1, 4, 6
• Do not use corticosteroids for maintenance therapy—they are ineffective and cause long-term harm 1
• Always distinguish between ulcerative colitis and Crohn's disease before initiating treatment, as approaches differ significantly 4
• Consider alternative explanations for symptoms beyond active disease: bacterial overgrowth, bile salt malabsorption, fibrotic strictures, dysmotility 1, 4
• Avoid infliximab in patients with obstructive symptoms in Crohn's disease 1
• Monitor FBC within 4 weeks of starting azathioprine and every 6-12 weeks thereafter to detect neutropenia 1