Ulcerative colitis: management

Ulcerative colitis: management

Treatment can be divided into inducing and maintaining remission. NICE updated their guidelines on the management of ulcerative colitis in 2019.

The severity of UC is usually classified as being mild, moderate or severe:

• mild: < 4 stools/day, only a small amount of blood
• moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
• severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)

Inducing remission

Treating mild-to-moderate ulcerative colitis

• proctitis
  • topical (rectal) aminosalicylate
    In a mild-moderate flare of distal ulcerative colitis, the first-line treatment is topical (rectal) aminosalicylates
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    Importance: 97
    : for distal colitis rectal mesalazine has been shown to be superior to rectal steroids and oral aminosalicylates
  • if remission is not achieved within 4 weeks
    4 weeks
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    , add an oral aminosalicylate
    add an oral aminosalicylate
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  • if remission still not achieved add topical or oral corticosteroid
    If a mild-moderate flare of ulcerative colitis does not respond to topical or oral aminosalicylates then oral corticosteroids are added
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    Importance: 90
• proctosigmoiditis and left-sided ulcerative colitis
  • topical (rectal) aminosalicylate
    In a mild-moderate flare of distal ulcerative colitis, the first-line treatment is topical (rectal) aminosalicylates
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    Importance: 97
  • if remission is not achieved within 4 weeks, add a high-dose oral aminosalicylate
    add a high-dose oral aminosalicylate
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    OR switch to a high-dose oral aminosalicylate and a topical corticosteroid
  • if remission still not achieved stop topical treatments and offer an oral aminosalicylate and an oral corticosteroid
    If a mild-moderate flare of ulcerative colitis does not respond to topical or oral aminosalicylates then oral corticosteroids are added
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    Importance: 90
• extensive disease
  • topical (rectal) aminosalicylate and a high-dose oral aminosalicylate
    In a mild-moderate flare of ulcerative colitis extending past the left-sided colon, oral aminosalicylates should be added to rectal aminosalicylates, as enemas only reach so far
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    Importance: 95
    :
  • if remission is not achieved within 4 weeks, stop topical treatments and offer a high-dose oral aminosalicylate and an oral corticosteroid
    If a mild-moderate flare of ulcerative colitis does not respond to topical or oral aminosalicylates then oral corticosteroids are added
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    Importance: 90

Severe colitis

• should be treated in hospital
  A severe flare of ulcerative colitis should be treated in hospital with IV corticosteroids
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  Importance: 98
• IV steroids are usually given first-line
  A severe flare of ulcerative colitis should be treated in hospital with IV corticosteroids
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  Importance: 98
  • IV ciclosporin may be used if steroids are contraindicated
• if after 72 hours there has been no improvement, consider adding IV ciclosporin to IV corticosteroids or consider surgery
  adding IV ciclosporin to IV corticosteroids or consider surgery
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Maintaining remission

Following a mild-to-moderate ulcerative colitis flare

• proctitis and proctosigmoiditis
  proctitis and proctosigmoiditis
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  • topical (rectal) aminosalicylate alone (daily or intermittent) or
  • an oral aminosalicylate plus a topical (rectal) aminosalicylate (daily or intermittent) or
  • an oral aminosalicylate by itself: this may not be effective as the other two options
• left-sided and extensive ulcerative colitis
  left-sided and extensive ulcerative colitis
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  • low maintenance dose of an oral aminosalicylate

Following a severe relapse or >=2 exacerbations in the past year

• oral azathioprine or oral mercaptopurine
  If a patient with ulcerative colitis has had a severe relapse or >=2 exacerbations in the past year they should be given either oral azathioprine or oral mercaptopurine to maintain remission
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  Importance: 87

Other points

• methotrexate is not recommended for the management of UC (in contrast to Crohn's disease)
• there is some evidence that probiotics may prevent relapse in patients with mild to moderate disease

Surgical management

Surgery is considered when UC is unresponsive to optimal medical therapy or in the presence of serious complications such as toxic megacolon or perforation.

Subtotal colectomy

• involves removal of part of the colon, usually with a temporary loop ileostomy to protect the anastomosis
• the ileostomy may be reversed later.

Restorative proctocolectomy (IPAA)

• this is the preferred approach rather than complete proctocolectomy
• involves total colectomy with the formation of an ileal pouch joined to the anal canal (IPAA)
• a temporary loop ileostomy is created and later reversed.

Complete panproctocolectomy

Complete panproctocolectomy

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• involves removal of the entire colon and rectum, resulting in a permanent ileostomy as no anastomosis is performed

+PassMedicine Notes

Treatment can be divided into inducing and maintaining remission. NICE updated their guidelines on the management of ulcerative colitis in 2019.

The severity of UC is usually classified as being mild, moderate or severe:

• mild: < 4 stools/day, only a small amount of blood
• moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
• severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)

Inducing remission

Treating mild-to-moderate ulcerative colitis

• proctitis
• topical (rectal) aminosalicylate: for distal colitis rectal mesalazine has been shown to be superior to rectal steroids and oral aminosalicylates
• if remission is not achieved within 4 weeks, add an oral aminosalicylate
• if remission still not achieved add topical or oral corticosteroid
• proctosigmoiditis and left-sided ulcerative colitis
• topical (rectal) aminosalicylate
• if remission is not achieved within 4 weeks, add a high-dose oral aminosalicylate OR switch to a high-dose oral aminosalicylate and a topical corticosteroid
• if remission still not achieved stop topical treatments and offer an oral aminosalicylate and an oral corticosteroid
• extensive disease
• topical (rectal) aminosalicylate and a high-dose oral aminosalicylate:
• if remission is not achieved within 4 weeks, stop topical treatments and offer a high-dose oral aminosalicylate and an oral corticosteroid

Severe colitis

• should be treated in hospital
• IV steroids are usually given first-line
• IV ciclosporin may be used if steroids are contraindicated
• if after 72 hours there has been no improvement, consider adding IV ciclosporin to IV corticosteroids or consider surgery

Inducing Remission in Ulcerative Colitis

Maintaining remission

Following a mild-to-moderate ulcerative colitis flare

• proctitis and proctosigmoiditis
• topical (rectal) aminosalicylate alone (daily or intermittent) or
• an oral aminosalicylate plus a topical (rectal) aminosalicylate (daily or intermittent) or
• an oral aminosalicylate by itself: this may not be effective as the other two options
• left-sided and extensive ulcerative colitis
• low maintenance dose of an oral aminosalicylate

Following a severe relapse or >=2 exacerbations in the past year

• oral azathioprine or oral mercaptopurine

Maintaining remission in Ulcerative Colitis

Other points

• methotrexate is not recommended for the management of UC (in contrast to Crohn's disease)
• there is some evidence that probiotics may prevent relapse in patients with mild to moderate disease

Surgical management

Surgery is considered when UC is unresponsive to optimal medical therapy or in the presence of serious complications such as toxic megacolon or perforation.

Subtotal colectomy

• involves removal of part of the colon, usually with a temporary loop ileostomy to protect the anastomosis
• the ileostomy may be reversed later.

Restorative proctocolectomy (IPAA)

• this is the preferred approach rather than complete proctocolectomy
• involves total colectomy with the formation of an ileal pouch joined to the anal canal (IPAA)
• a temporary loop ileostomy is created and later reversed.

Complete panproctocolectomy

• involves removal of the entire colon and rectum, resulting in a permanent ileostomy as no anastomosis is performed