What is the treatment for an ulcerative colitis (UC) flare?

From the Guidelines

Treatment for ulcerative colitis flares should involve a step-up approach, with moderate to severe cases being treated with oral corticosteroids such as prednisolone 40 mg daily, weaning over 6–8 weeks, as recommended by the British Society of Gastroenterology consensus guidelines 1.

Key Considerations

• For mild to moderate flares, 5-aminosalicylates (5-ASAs) like mesalamine are first-line treatments, given orally at doses of 2.4-4.8g daily or rectally as suppositories or enemas for distal disease.
• If symptoms persist, oral corticosteroids such as prednisone 40mg daily with a gradual taper over 8-12 weeks are added, as supported by the Toronto consensus 1.
• For severe flares, hospitalization may be necessary with intravenous corticosteroids (methylprednisolone 40-60mg daily), and if there's no improvement within 3-5 days, rescue therapy with infliximab (5-10mg/kg IV), cyclosporine (2mg/kg IV), or colectomy should be considered, as suggested by the third European evidence-based consensus on diagnosis and management of ulcerative colitis 1.

Additional Therapies

• Supportive care including hydration, electrolyte replacement, and nutritional support is essential throughout treatment.
• Antibiotics are only used if infection is suspected.
• Maintenance therapy with 5-ASAs, immunomodulators, or biologics is crucial to prevent future flares after achieving remission.

Recent Guidelines

• The British Society of Gastroenterology consensus guidelines recommend oral corticosteroids for moderate to severe ulcerative colitis, with a strong recommendation and high-quality evidence 1.
• The Toronto consensus and the third European evidence-based consensus provide additional guidance on the management of ulcerative colitis, including the use of 5-ASAs, corticosteroids, and biologics 1.

From the FDA Drug Label

1. 3 Ulcerative Colitis RENFLEXIS is indicated for reducing signs and symptoms, inducing and maintaining clinical remission and mucosal healing, and eliminating corticosteroid use in adult patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy.
2. 3 Ulcerative Colitis The recommended dose of RENFLEXIS is 5 mg/kg given as an intravenous induction regimen at 0,2 and 6 weeks followed by a maintenance regimen of 5 mg/kg every 8 weeks thereafter for the treatment of adult patients with moderately to severely active ulcerative colitis.

The treatment for ulcerative colitis flare is Infliximab (IV), with a recommended dose of 5 mg/kg given as an intravenous induction regimen at 0,2, and 6 weeks, followed by a maintenance regimen of 5 mg/kg every 8 weeks. This treatment is indicated for adult patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy 2.

From the Research

Treatment Options for Ulcerative Colitis Flare

• The treatment for ulcerative colitis (UC) flare depends on the severity of the disease, with mild-to-moderate UC managed with aminosalicylates, mesalamine, and topical corticosteroids 3, 4, 5, 6.
• Oral corticosteroids are reserved for unresponsive cases of mild-to-moderate UC, while moderate-to-severe UC generally requires oral or intravenous corticosteroids in the short-term 3, 7.
• Biologic agents or thiopurines may be considered for long-term management of moderate-to-severe UC, as initial therapy or in transition from steroids 3.
• Patients with severe or fulminant UC who are recalcitrant to medical therapy or develop disease complications may require colectomy, and early surgical referral is crucial 3.

Medication Options

• Mesalamine is a first-line therapy for inducing and maintaining clinical remission in patients with mild-to-moderate UC, with various formulations available, including MMX mesalamine 4, 5, 6.
• Corticosteroids, such as systemic corticosteroids or poorly absorbed steroids like Beclomethasone dipropionate and Budesonide MMX, are effective in inducing remission in mild to moderate flares not responding to combined oral and topical mesalazine 7.
• Topical administration of corticosteroids is an effective alternative to topical mesalazine in mild-moderate distal disease 7.

Considerations

• Treatment strategies must take into account the current clinical presentation, extent and severity of disease activity, and long-term treatment options 3.
• Frequent assessments are required to determine clinical response, and treatment intensification may be warranted if expected improvement goals are not reached 3.
• Patient adherence to mesalamine therapy can be improved with simplified pill regimens, such as once-daily formulations 4.