You'll hear more about treating patients hospitalized with ACUTE severe ulcerative colitis...due to updated guidelines.
Up to 1 in 4 ulcerative colitis patients will be hospitalized for a severe flare. This includes 6 or more bloody stools/day PLUS at least one systemic sign...fever, anemia, elevated C-reactive protein (CRP), etc.
Rule out C. diff. It can mimic an ulcerative colitis flare...and is associated with increased mortality in these patients.
Assess for triggers...such as NSAIDs, recently started mesalamine or another aminosalicylate, or nonadherence to maintenance meds.
Start with IV methylprednisolone 60 mg/day...or hydrocortisone 300 to 400 mg/day. There's no evidence higher steroid doses are better.
Add rectal steroids if needed for additional relief.
Transition IV steroids to oral in 3 days if the patient responds. Look for improved vital signs, decreased pain or CRP, fewer stools, etc. But IV steroids won't work in about one-third of patients.
If there's no improvement in 3 to 5 days, add rescue infliximab or IV cyclosporine to try to avoid a colectomy. They seem equally effective.
But lean away from cyclosporine in patients who failed an outpatient immunomodulator, such as azathioprine or mercaptopurine.
Don't routinely add antibiotics. They don't seem to improve outcomes in most cases. Save antibiotics for patients at high risk of infection, such as those with sepsis, toxic megacolon, or perforated colon.
Try to avoid opioids or anticholinergics...since slowing the gut may increase the risk of toxic megacolon.
Work with the GI specialist to transition to outpatient treatment. For example, anticipate discharging on prednisone for 2 to 3 months. And infliximab patients will need their next dose 2 weeks after the first.
Verify all patients have a follow-up appointment within about 1 week.
Get our chart, Acute Severe Ulcerative Colitis FAQs, for more on dosing, adjunctive treatments, and transition to maintenance therapy.
- Am J Gastroenterol 2019;114(3):384-413
- Lancet 2012;380(9857):1909-15
- Inflamm Bowel Dis 2019;25(1):56-66