What is the best course of action for a patient with acute ulcerative colitis, iron deficiency anemia, and thrombocytosis currently taking 35mg oral (PO) Prednisone daily (qd)?

Management of Acute Ulcerative Colitis on 35mg Prednisone Daily

This patient requires immediate assessment of steroid response and consideration for treatment escalation, as the current 35mg prednisone dose is suboptimal and prolonged steroid therapy beyond 2 weeks without adequate response increases surgical morbidity and mortality.

Immediate Steroid Dose Optimization

The current 35mg prednisone dose should be increased to 40mg daily, as this is the evidence-based standard dose for moderate-to-severe ulcerative colitis. 1

• Prednisolone 40mg daily is more effective than 20mg daily, with no additional benefit from doses exceeding 40-60mg daily 1
• The dose should be administered as a single morning dose (before 9am) to minimize adrenal suppression 2
• A 6-8 week taper is recommended once remission is achieved 1

Assessment of Treatment Response

Evaluate response to oral corticosteroids within 2 weeks, as patients not responding after this timeframe should be escalated to advanced therapy or hospitalized depending on systemic symptoms. 1

Clinical indicators requiring escalation or hospitalization: 1

• Fever, severe pain, or significant systemic unwellness
• Presence of tachycardia, significant anemia, or elevated inflammatory markers (CRP, ESR)
• Inability to tolerate symptoms despite treatment
• More than 6 bloody stools per day with systemic features

Treatment Escalation Strategy

If inadequate response after 2 weeks of optimal-dose oral steroids, initiate advanced therapy with anti-TNF agents (infliximab), vedolizumab, or tofacitinib rather than prolonging steroid exposure. 1

• Prolonging high-dose oral corticosteroids beyond 2 weeks has diminishing efficacy and increases risk of infectious, metabolic, and surgical complications 1
• Patients requiring two or more steroid courses in the past year or becoming steroid-dependent require treatment escalation 1

Management of Iron Deficiency Anemia

Treating the underlying UC inflammation is the essential first step, but iron supplementation must be initiated concurrently as inflammation control alone rarely normalizes hemoglobin. 1

Iron supplementation approach: 1

• For mild anemia (Hb >10 g/dL): Oral iron sulfate 100mg daily is adequate
• For moderate-to-severe anemia or active inflammation: Intravenous iron is preferred over oral iron due to better efficacy and avoidance of GI side effects that may exacerbate IBD
• Oral iron generates reactive oxygen species that can potentially worsen UC activity 1

Diagnostic considerations for anemia: 1

• In the presence of inflammation, ferritin <100 μg/L suggests iron deficiency (not <15 μg/L as in non-inflammatory states)
• Transferrin saturation <16% is sensitive for iron deficiency
• Check vitamin B12 and folate levels at least annually 1, 3
• Never initiate folate supplementation before ruling out and treating B12 deficiency, as this can precipitate irreversible subacute combined degeneration of the spinal cord 3

Management of Thrombocytosis

The thrombocytosis is reactive and secondary to both inflammation and iron deficiency; it will resolve with control of UC activity and correction of anemia. 4, 5

• Platelet count correlates with disease activity (CRP, clinical indices), hemoglobin levels, and iron deficiency parameters in IBD 5
• Thromboprophylaxis with low-molecular-weight heparin should be considered if the patient requires hospitalization or has additional thrombotic risk factors 1
• Thrombocytosis in UC increases risk of venous thromboembolism, particularly during active disease 4

Maintenance Therapy Planning

Once remission is achieved, continue maintenance with high-dose 5-ASA (≥2g daily) and discontinue corticosteroids completely. 1

• Corticosteroids are never appropriate for long-term maintenance therapy 1
• If the patient required escalation to biologics or small molecules, continue the agent that successfully induced remission 1
• Thiopurines can be considered for maintenance, particularly alongside infliximab therapy 1

Monitoring Parameters

Monitor hemoglobin every 6 months during active disease and every 12 months in remission to detect recurrent anemia, which indicates ongoing intestinal inflammation. 1

• An acceptable response to iron therapy is hemoglobin increase ≥2 g/dL within 4 weeks 3
• Recurrence of anemia occurs in >50% of patients after 1 year and often indicates ongoing inflammation 1

Critical Pitfall to Avoid

Do not continue oral prednisone beyond 2 weeks without clear clinical improvement, as this increases colectomy-related morbidity without improving outcomes. 1 The patient is already at suboptimal dosing (35mg vs. 40mg), and any delay in recognizing steroid failure and escalating therapy compromises both short-term safety and long-term disease control.