What is the first-line therapy for an 18-year-old male with a flare of ulcerative colitis (UC), presenting with frequent bloody stools, low-grade fever, chills, and anemia, who is hemodynamically stable?

From the Guidelines

For an 18-year-old male with an ulcerative colitis flare presenting with 6-10 bloody stools daily, low-grade fever, chills, and hemoglobin of 10 g/dL, IV methylprednisolone 60 mg every 24 hours would be the first-line therapy. This recommendation is based on the most recent and highest quality study available, which emphasizes the importance of intravenous corticosteroids in the management of moderate to severe ulcerative colitis flares requiring hospitalization 1. The patient's presentation with frequent bloody stools, systemic symptoms, and anemia indicates a moderate to severe flare that requires prompt intervention.

Key Considerations

• Intravenous corticosteroids, such as methylprednisolone, are the mainstay of treatment for moderate to severe UC flares requiring hospitalization, as they work rapidly to reduce inflammation in the colon by suppressing the inflammatory cascade and immune response.
• The dose of IV methylprednisolone recommended is 60 mg every 24 hours, which is consistent with guidelines that suggest doses of 40–60mg/day or equivalent are the mainstay of therapy for hospitalized patients with acute severe ulcerative colitis (ASUC) 1.
• While infliximab (an anti-TNF agent) and cyclosporine are effective for steroid-refractory UC, they are typically considered second-line therapies after corticosteroids have failed.
• Proctocolectomy is a surgical intervention reserved for patients with severe disease unresponsive to medical management, complications such as toxic megacolon, or those with dysplasia/cancer, making it inappropriate as first-line therapy for an acute flare.

Management Approach

• The management of ulcerative colitis involves a multidisciplinary approach, including joint care by a gastroenterologist and a colorectal surgeon, especially in cases of severe disease or when surgery is being considered.
• Patients should receive adequate volumes of intravenous fluids, and low-molecular-weight heparin for thromboprophylaxis; electrolyte abnormalities and anemia should be corrected, if needed, as part of the initial management strategy 1.
• The use of biologic agents like infliximab may be considered in patients who are refractory to corticosteroids, but this would be after the failure of first-line therapy with IV corticosteroids 1.

Evidence Summary

The evidence from recent studies and guidelines supports the use of IV methylprednisolone as the first-line therapy for moderate to severe ulcerative colitis flares, highlighting its effectiveness in rapidly reducing inflammation and managing symptoms 1. The recommendation to use IV methylprednisolone 60 mg every 24 hours is based on the highest quality and most recent evidence available, prioritizing the patient's morbidity, mortality, and quality of life outcomes.

From the FDA Drug Label

In addition, a greater proportion of patients in infliximab groups demonstrated sustained response and sustained remission than in the placebo groups The improvement with infliximab was consistent across all Mayo subscores through Week 54 The first-line therapy for the patient's current condition is IV methylprednisolone 60 mg every 24 hours.

• Infliximab is not typically used as first-line therapy for acute ulcerative colitis exacerbations.
• Cyclosporine may be considered for severe ulcerative colitis that is refractory to corticosteroids.
• Proctocolectomy is typically considered a last resort for patients with severe ulcerative colitis that is refractory to medical therapy. 2

From the Research

First-Line Therapy for Acute Severe Ulcerative Colitis

The patient presents with a flare of his ulcerative colitis (UC), reporting 6 to 10 bloody stools daily associated with low-grade fever and chills, and a hemoglobin level of 10 g/dL. Given his condition, the first-line therapy for his current condition would be:

• IV methylprednisolone 60 mg every 24 hours 3, 4

Rationale

Intravenous corticosteroids, such as methylprednisolone, remain the first-line treatment for acute severe ulcerative colitis 3. This approach is supported by studies that highlight the importance of effective medical treatment or timely colectomy in managing this potentially lethal condition 3, 4.

Alternative Options

Other options, such as infliximab or cyclosporine, may be considered as rescue therapy in patients who do not respond to corticosteroids after 3-5 days 3. However, these alternatives are not considered first-line therapy for the initial management of acute severe ulcerative colitis.

Recent Studies

Recent studies have explored the efficacy of combining corticosteroids with infliximab as first-line therapy for acute severe ulcerative colitis with mucosal deficiency, showing promising results in terms of endoscopic improvement and durable clinical remission 5. Additionally, new biologics and small molecules have been approved, offering emerging roles in the management of acute severe ulcerative colitis 6.