Ulcerative Colitis Management

Initial Therapy

• For mild to moderate ulcerative colitis, the first-line treatment is oral 5-aminosalicylates (5-ASA) compounds, with dosing dependent on disease location and severity, as recommended by the European Crohn's and Colitis Organisation and the European Society of Gastrointestinal Endoscopy 1, 2
• Topical 5-ASA therapy (1g daily) is the first-line treatment for ulcerative proctitis, and if there is an inadequate response, oral 5-ASA (2-4g daily) or topical corticosteroids can be added, as recommended by the European Society of Gastrointestinal Endoscopy 1
• Oral prednisolone 40mg daily can be combined with 5-ASA as initial therapy, and high-dose 5-ASA alone can be tried, but corticosteroids should be initiated if there is no response within 2 weeks, as recommended by the European Society of Gastrointestinal Endoscopy 1
• The treatment goals have shifted from clinical response to achieving biochemical, endoscopic, and histological remission, according to the American Gastroenterological Association 1, 2

Treatment Escalation

• If there is no response to oral 5-ASA within 2-4 weeks, oral prednisolone 40mg daily can be added, as recommended by the European Crohn's and Colitis Organisation and the European Society of Gastrointestinal Endoscopy 1
• Prednisolone should be tapered over 8 weeks once a response is achieved, as recommended by 3

Advanced Therapy Options

• The American Gastroenterological Association recommends considering TNF antagonists (infliximab, adalimumab, golimumab), integrin inhibitors (vedolizumab), IL-12/23 inhibitors (ustekinumab), JAK inhibitors (tofacitinib, upadacitinib), and S1P receptor modulators (ozanimod, etrasimod) for advanced therapy options 4
• TNF antagonists are more effective when combined with immunomodulators, as recommended by the American Gastroenterological Association and the European Society of Gastrointestinal Endoscopy 4, 5, 2, 6
• JAK inhibitors have restrictions recommending use after TNF antagonist failure, as recommended by the American Gastroenterological Association 4

Maintenance Therapy

• The European Crohn’s and Colitis Organisation recommends continuing the agent that successfully induced remission for moderate to severe disease, and corticosteroids should never be used for long-term maintenance, as recommended by the European Crohn's and Colitis Organisation and the European Society of Gastrointestinal Endoscopy 1, 2, 7
• All patients should receive maintenance therapy with 5-ASA compounds at ≥2g/day for lifelong use, as higher doses are more effective for maintenance, especially in extensive disease, as recommended by the European Crohn's and Colitis Organisation 7, 2
• Options for maintenance therapy include aminosalicylates, azathioprine or mercaptopurine, and biologics for refractory disease, as recommended by the American Gastroenterological Association 2

Hospitalization and Rescue Therapy

• The American College of Gastroenterology recommends assessing response to IV corticosteroids by day 3, and considering rescue therapy with ciclosporin, infliximab, or tacrolimus for non-responders, as recommended by 8
• Colectomy should be considered if there is no improvement after 4-7 days of salvage therapy, as recommended by 8
• The following medications are used in severe disease:

Supportive Care

• The European Society of Gastrointestinal Endoscopy recommends venous thromboembolism prophylaxis with low-molecular-weight heparin, nutritional support if malnourished, and avoiding anticholinergics, anti-diarrheals, NSAIDs, and opioids during acute flares, as recommended by the European Society of Gastrointestinal Endoscopy and the American College of Gastroenterology 8, 9, 10
• Patients should drink adequate fluids, avoid foods that worsen symptoms, and consider small, frequent meals rather than large meals, and stay current with vaccinations, especially if on immunosuppressive therapy, as recommended by the American College of Gastroenterology 9
• Moderate exercise is beneficial when symptoms are controlled, and rest is appropriate during symptom flares, and patients should keep a symptom diary to track their symptoms and identify triggers, as recommended by the American College of Gastroenterology 9
• Smoking cessation is crucial for maintaining remission, as recommended by the European Crohn's and Colitis Organisation 2