Two complementary articles provide extensive guidance on the management of ulcerative colitis and acute severe colitis:
- D Turner et al. JPGN 2018; 67: 257-91
- D Turner et al. JPGN 2018; 67: 292-310
Between the two articles there are more than 60 practice recommendations, more than 120 practice points, and more than 700 references. As such, these articles are probably better for a journal review meeting rather than a brief blog post.
Figure 1 (2nd article, page 299) provides a handy algorithm for management of acute severe colitis:
- On day 1-2, the algorithm recommends stool studies, starting methylprednisolone, and withholding 5-ASA.
- On day 3, if PUCAI <45, suggests continuing steroid and transitioning to oral therapy when PUCAI <35. On day 3, if PUCAI ≥45, the authors suggest screening for second line therapy, involve surgery (to discuss colectomy if there is nonresponse to medical treatment), and looking for CMV infection (eg. sigmoidoscopy).
- On day 5, if PUCAI >65, recommendation is to start 2nd line Rx (eg. infliximab, tacrolimus, or cyclosporine). If PUCAI 35-65, continue corticosteroids for additional 2-5 days. The authors note that infliximab is preferred 2nd line Rx unless planning to transition to vedolizumab.
- The authors recommend weaning corticosteroids when 2nd line Rx is started
- The authors recommend addition of an immunomodulator for at least 6 months in responders to infliximab in effort to lower the risk of colectomy.
- The authors state “urgent colectomy is recommended following failure of 1 second-line therapy.”
Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.
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