mild or moderate attacks confined to the rectum or descending colon

Last edited 07/2019

  • rectal corticosteroids or aminosalicylates are the treatment of choice; suppositories are used for local rectal disease while enemas are required where IBD affects the proximal descending colon; foams only act up to the distal descending colon (3)

  • oral steroids, and rarely surgery, may be required for resistant cases

  • other treatment options for refractory cases include fibre supplements or methycellulose to relieve proximal constipation and, sometimes, oral azathioprine (2)

With respect to inducing remission in ulcerative colitis (4,5):

Pharmacological management -inducing remission in mild-to-moderate ulcerative colitis

    • Proctitis
      • a topical aminosalicylate (U1) is first-line treatment for people with a mild-to-moderate first presentation or inflammatory exacerbation of proctitis

      • if remission is not achieved within 4 weeks, consider adding an oral aminosalicylate (U2)

      • if further treatment is needed, consider adding a time-limited course of a topical or oral corticosteroid (U3) (normally 4-8 weeks, depending on the steroid)

      • for people who decline a topical aminosalicylate:
        • consider an oral aminosalicylate as first-line treatment, and explain that this is not as effective as a topical aminosalicylate
        • if remission is not achieved within 4 weeks, consider adding a time-limited course of a topical or oral corticosteroid (U4)

      • for people who cannot tolerate aminosalicylates, consider a time-limited course of a topical or oral corticosteroid

    • Proctosigmoiditis and left-sided ulcerative colitis
      • a topical aminosalicylate is first-line treatment for people with a mild-to-moderate first presentation or inflammatory exacerbation of proctosigmoiditis or left-sided UC

      • if remission is not achieved within 4 weeks, consider:
        • adding a high-dose oral aminosalicylate, OR
        • switching to a high-dose oral aminosalicylate and a time-limited course of a topical corticosteroid

      • if further treatment is needed, stop topical treatments and offer an oral aminosalicylate and a time-limited course of an oral corticosteroid

      • for people who decline any topical treatment:
        • consider a high-dose oral aminosalicylate alone, and explain that this is not as effective as a topical aminosalicylate.
        • if remission is not achieved within 4 weeks, offer a time-limited course of an oral corticosteroid in addition to the high-dose aminosalicylate

      • for people who cannot tolerate aminosalicylates, consider a time-limited course of a topical or an oral corticosteroid

    • Extensive disease
      • a combination of a topical aminosalicylate and a high-dose oral aminosalicylate is first-line treatment for people with a mild-to-moderate first presentation or inflammatory exacerbation of extensive UC

      • if remission is not achieved within 4 weeks, stop the topical aminosalicylate and offer a high-dose oral aminosalicylate and a time-limited course of an oral corticosteroid

      • for people who cannot tolerate aminosalicylates, consider a time-limited course of a topical or oral corticosteroid

Inducing remission in moderately to severely active ulcerative colitis

All extents of disease

    • infliximab, adalimumab and golimumab
      • recommended, within their marketing authorisations, as options for treating moderately to severely active ulcerative colitis in adults whose disease has responded inadequately to conventional therapy including corticosteroids and mercaptopurine or azathioprine, or who cannot tolerate, or have medical contraindications for, such therapies

    • vedolizumab
      • recommended, within its marketing authorisation, as an option for treating moderately to severely active ulcerative colitis in adults only if the company provides vedolizumab with the discount agreed in the patient access scheme

    • tofacitinib
      • recommended, within its marketing authorisation, as an option for treating moderately to severely active ulcerative colitis in adults when conventional therapy or a biological agent cannot be tolerated or the disease has responded inadequately or lost response to treatment

If acute severe ulcerative colitis

All extents of disease

Step 1 therapy

  • for people admitted to hospital with acute severe UC (either a first presentation or an inflammatory exacerbation):
    • intravenous corticosteroids should be offered to induce remission AND
    • assess the likelihood that the person will need surgery

  • consider intravenous ciclosporin (U4) or surgery for people:
    • who cannot tolerate or who decline intravenous corticosteroids, OR
    • for whom treatment with intravenous corticosteroids is contraindicated

  • clinician's must tsake into account the person's preference when choosing treatment

Step 2 therapy

  • consider adding intravenous ciclosporin U4 to intravenous corticosteroids or consider surgery for people:
    • who have little or no improvement within 72 hours of starting intravenous corticosteroids, OR,
    • whose symptoms worsen at any time despite corticosteroid treatment

  • take into account the person's preference when choosing treatment.
    • infliximab is recommended as an option for the treatment of acute exacerbations of severely active UC only in patients in whom ciclosporin is contraindicated or clinically inappropriate, based on a careful assessment of the risks and benefits of treatment in the individual patient.
    • in people who do not meet this criterion, infliximab should only be used for the treatment of acute exacerbations of severely active UC in clinical trials

Prescribers are advised to check the Full guideline (1) for detailed guidance.

Notes:

  • antidiarrhoeal agents do not reduce stool frequency in colitis and increase the risk of toxic megacolon (2)
  • antibiotics are indicated if doubt exists about the diagnosis (for example, in the case of a first attack) or if the patient has recently travelled to an area where amoebic dysentery is endemic (2)
    • empirical treatment with metronidazole and a quinolone can be started
    • stool should be taken for culture (including assessment of C difficile toxin) in all patients

  • Unlicensed prescribing
    • U1 - some topical aminosalicylates are not licensed for this indication in children and young people.
    • U2 - some oral aminosalicylates are not licensed for this indication in children and young people.
    • U3 - beclometasone dipropionate only has a UK marketing authorisation 'as add-on therapy to 5-ASA containing drugs in patients who are non-responders to 5-ASA therapy in active phase'. Additionally, budesonide (oral or rectal) and prednisolone foam are not licensed in children.
    • U4 - ciclosporin is not licensed for this indication

  • distal ulcerative colitis:
    • topical treatments (suppositories) can be used for disease that extends to the rectosigmoid junction (5)
    • if more proximal disease then foam or liquid enemas are useful (5)
    • topical corticosteroids are probably less effective than topical mesalazine at achieving remission (5)
      • clinical (and endoscopic) remission may be evident in up to 64% (52%) within 2 weeks of topical mesalazine therapy
      • topical steroids can be used as a second line therapy in patients who are intolerant to topical mesalazine (6)
    • rectal prednisolone or hydrocortisone should not be used long term because can have considerable side effect - up to 50% is absorbed systemically (5)
      • there is rapid metabolisation of steroids in the liver and therefore steroids that are rapidly metabolised in the liver, such as prednisolone metasulfobenzoate, are less likely to cause systemic side effects
    • oral mesalazine alone or topical mesalazine alone are equally effective treatments - however combined treatment is more beneficial
    • oral corticosteroids may be needed if topical and oral therapy are ineffective
    • additional oral mesalazine or, alternatively, oral prednisolone may be required in patients who have treatment failure with topical mesalazine and topical corticosteroids (5,6)
  • acute left-sided and extensive disease:
    • doses of oral mesalazine >3 g per day are more effective than lower doses (5)
    • combined topical mesalazine and oral mesalazine treatment can be effective in inducing remission in left sided colitis and extensive colitis
    • oral steroids are indicated in mild disease that fails to respond to topical treatment; also oral steroids are indicated in moderate disease (for example, patients with bloody diarrhoea)

Notes:

  • severe colitis should be urgently referred to hospital
  • steroids are used to induce remission in relapses of ulcerative colitis. however they have no role in maintenance therapy (5)

Reference: