Ulcerative colitis (Guidelines)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Audience

  • All NHS Highland 
  • Primary and Secondary Care
  • Adults only

Guidance on how to manage and assess mild to moderate and severe ulcerative colitis with recommendations on when to consider acute severe colitis and need to refer to secondary care.

Definition of severe ulcerative colitis (UC):

  • 6 or more bloody stools per day and at least one of the following: 
    • Temperature greater than 37.8oC
    • Pulse > 90 per minute
    • Haemoglobin < 105g/L
    • CRP > 45
    • Exclusion of infection
    • Stool culture and sensitivity and clostridium difficile; travel history

Primary Care management

Note: A Primary Care Pathway is expected shortly from the Centre For Sustainable Delivery. 

Ulcerative colitis flare

IBD flare line: 01463 705167

Please arrange investigations and consider below:

  • Check stool cultures / C. Diff / travel history
  • Update bloods: FBC, U&Es, LFTs and CRP
  • Has the patient been unwell or has there been recent antibiotic use?
  • Has there been any new medications introduced, such as NSAIDs or Iron?
  • Has Coeliac been ruled out and is there an irritable bowel history (IBS)?

Disease severity

Level of Disease Severity Frequency of bloody stool with or without blood each day

Is there systemic upset?

Pulse >90, Temp >37.8, HB <105
CRP >30

Mild

<4 each day

No

Moderate

4 to 5 each day

No 

Severe

≥6

Yes: one or more features of systemic upset. NB CRP >45

Condition management

Proctitis 

  • Inflammation restricted to the rectum
Mild to moderate disease Moderate to severe disease Severe disease

Mesalazine: 1g suppository at night 

If no response in 2 weeks, consider:

  • Increasing suppository to 1g twice daily.
  • Add oral mesalazine: 2g or 2.4g twice daily

If intolerant of suppositories, consider: 

  • Switching to oral mesalazine, as above

Optimise oral mesalazine to 4 or 4.8g in divided doses

Consider adding topical corticosteroid: prednisolone suppositories, 5mg twice daily

If previous measures are ineffective, consider:

  • Switch from topical to oral corticosteroid: Prednisolone reducing course, starting at 40mg orally once daily, reducing by 5mg every 7 days, until 0.
  • Consider bone and gastro protection, if appropriate.

If all previous measures are ineffective:

  • Seek advice from Gastroenterology / IBD Team.

Distal / left sided colitis 

  • Treatment will depend upon disease distribution / extent
  • Faecal calprotectin as advised by the IBD team
Mild to moderate disease Moderate to severe disease Severe disease

Oral mesalazine 2 or 2.4g once daily
AND mesalazine suppository 1g at night OR mesalazine enema 2g at night

If no response:

  • Optimise oral mesalazine dose to 4 or 4.8g twice daily.
  • Add topical treatment (as above) if not already added

If no response to mesalazine optimisation:

  • Add Cortiment® (budesonide MMX) 9mg MR tablets, once a day for 8 weeks

Cortiment® is preferred as it undergoes extensive first pass metabolism, meaning that much less drug is systemically absorbed, resulting in fewer steroid-related adverse effects. 

If previous measures are ineffective:

  • Seek advice from Gastroenterology / IBD team
  • Consider switching from  Cortiment® to prednisolone reducing course: starting at 40mg orally once daily, reducing by 5mg every 7 days until 0
  • Consider bone protection

Extensive / pan ulcerative colitis

  • Extensive colitis / pancolitis
  • Faecal calprotectin as advised by the IBD team
Mild to moderate disease Moderate to severe disease Severe disease

Oral mesalazine 2 to 2.4g once daily AND mesalazine 2g enema at night

If no response after 2 weeks:

  • Optimise oral mesalazine dose to 4 to 4.8g twice daily.
  • Add topical treatment (as abve) if not already added.

If no response to mesalazine optimisation:

  • Switch to: Cortiment® (budesonide MMX) 9mg MR tablets, once a day for 8 weeks

Cortiment® is preferred as it undergoes extensive first pass metabolism, meaning that much less drug is systemically absorbed, resulting in fewer steroid-related adverse effects. 

If previous measures are ineffective:

  • Seek advice from the Gastroenterology / IBD Team
  • Consider switching from  Cortiment® to prednisolone reducing course: starting at 40mg orally once daily, reducing by 5mg every 7 days until 0
  • Consider bone protection

Mesalazine is to be prescribed by brand:

Referral process

  • Patients are referred via SCI Gateway

Ongoing management

  • See DMARD monitoring
  • For any queries / further information: contact the specialist team through clinical dialogue.

Secondary Care management

Admission

All patients admitted to Raigmore with severe UC, should be transferred to Ward 7C, under Gastroenterology.

Early discussion of patients admitted to other Highlands Hospitals is encouraged via nhsh.gastroenterology@nhs.scot or direct phone discussion with the on-call consultant (Monday to Friday, 8am to 5pm).

Print and complete Severe Ulcerative Colitis checklist (NHS Highland intranet access required).

Investigations:

  • Bloods: FBC, U&E, CRP, LFT, Mg2+, lipids
  • CXR / AXR
  • Stool sample for culture and C Diff toxin
  • Weight
  • Endoscopic assessment: early flexible sigmoidoscopy with biopsy for CMV.

Unless results available within 1 year, and risk factors unchanged:

  • TB risk assessment
  • Viral screen: HBV, HCV, HIV, VZ IgG, EBV IgG/M, CMV IgG/M, Measles IgG, COVID IgG
  • TPMT

Daily review

  • Review of temperature, pulse, respiratory rate, BP
  • Abdominal examination
  • Stool charts
  • Daily bloods: FBC, U&E, Albumin, CRP
  • AXR if any deterioration, low threshold for CT

Escalation

Early surgical referral should be made if there are any signs of toxicity.

  • Referral should come from the Senior responsible Gastroenterologist to the Senior responsible Surgeon on-call, except at weekends, and peripheral hospitals.

Referral to Dietetics: 

  • Ward staff to refer patient to inpatient gastroenterology.
  • Note: There is no role for parenteral nutrition or gut rest by fasting.

Treatment (Secondary Care)

Steroids: 

  • IV methylprednisolone: 60mg, once daily for 3 days, then review.
  • This should NOT be delayed for culture results.

Oral 5-ASA:

  • Can be continued if patients were taking pre-admission, but DO NOT start new therapy until in remission.

Antibiotics:

  • Should NOT be routinely prescribed.

Bone protection: 

  • If <65 years: prescribe calcium and vitamin D preparation, as per Highland Formulary:
    • Adcal D3 chewable tablets, 2 tablets daily OR 
    • Adcal D3 caplets, 2 caplets twice daily
  • If >65 years or pre-existing osteoporosis: prescribe bisphosphonate along with calcium and vitamin D preparation, as per Highland Formulary:
    • Adcal D3 chewable tablets, 2 tablets daily OR
    • Adcal D3 caplets, 2 caplets twice daily
    • AND alendronic acid tablets, 70mg once weekly. Ensure patient is counselled to swallow whole, with a full glass of water while sitting or standing, on an empty stomach at least 30 minutes before breakfast and other medications. Patient should remain standing or sitting upright for at least 30 minutes after administration.

Thromboprophylaxis:

VTE prophylaxis should be considered for all patients admitted with UC regardless of mobility. This does NOT increase rectal bleeding.

  • If weight >50kg AND CrCl >30mL/min: consider enoxaparin 40mg, once daily
  • If weight <50kg OR CrCl <30mL/min: consider enoxaparin 20mg, once daily

IV fluid therapy: to correct dehydration, with at least 60mmol potassium per day.

  • Patients are highly prone to hypokalaemia due to the diarrhoea and steroid therapy. This requires close attention, particularly if surgery is being considered.

Analgesia: 

  • Use rectal / oral / IV paracetamol, as appropriate.
  • Ensure dose is reduced to 500mg up to four times daily in patients who weigh <50kg. 

Proximal constipation:

  • Treat proximal constipation if present in distal disease.
  • Often requires regular laxatives. Eg, Laxido sachets, 1 sachet as required.
  • Note: Be aware that lactulose may affect colonic pH and therefore alter 5-ASA release kinetics.

Drugs to avoid:

  • Anticholinergics, anti-diarrhoeal agents, NSAIDs and opioids, which risk precipitating colonic dilatation

Second-line therapy

A decision should be made on day 3 (between 48 and 72 hours of admission) whether or not the patient has responded to intravenous steroid.

When to consider second-line therapy:

  • Day 3: >8 stools per day or a CRP >45.
  • Day 7: >3 stools per day or passing stool with visible blood.
  • Surgery (request CT abdomen if considering surgery).

The choice of second line therapy should be personal to and personalised for the individual patient and should consider patient choice and the long-term treatment strategy.

If azathioprine has previously been used optimally (2.5mg/kg or proven therapeutic TGN levels) and failed, then either surgery, anti-TNF therapy, or vedolizumab may be needed in the long-term. Calcineurin inhibitors such as tacrolimus and ciclosporin are generally not used longer than for six months because of the risk of renal damage.

Ciclosporin:

  • Liaise with ward pharmacist:
  • IV ciclosporin: 2mg/kg given in 250mL normal saline over 24 hours.
  • Ensure non-PVC giving set is used. 
  • Check levels after 36 to 48 hours, and adjust the dose if necessary to achieve drug level of 100 to 200microg/L.
  • Send 5mL of blood sample in EDTA bottle to biochemistry. Blood levels are measured on what days?

Infliximab

  • 5mg/kg doses at 0, 2 and 6 weeks.
  • Inform the IBD co-ordinator nhsh.ibdcoordinator@nhs.scot at the earliest opportunity if infliximab is given, so the next infusion can be booked.

Remission

If improvement is seen, all treatments should be switched to oral from Day 5 to 7, where possible.

Steroid 

  • Prednisolone (oral) 40mg once daily for one week.
  • Then wean by 5mg per week.
  • Consider bone and gastro protection, as appropriate. 

Ciclosporin 

  • Ciclosporin (oral) (Neoral): 4 to 6mg/kg per day.
  • Check trough level at 1 week.
  • NB: Ciclosporin is usually used as a bridge to azathioprine or mercaptopurine treatment.
  • Consider commencing azathioprine or mercaptopurine (Consultant decision).
  • Aim to stop ciclosporin after 3 months when azathioprine / mercaptopurine is at full dose.

5-ASA

  • Eg, mesalazine (oral): 4g/day.
  • Start prior to discharge, or 2 weeks after acute flare up.

Patients should be reviewed two weeks after discharge in the out-patient clinic and be given details of IBD advice line in case of problems (01463 705167).

Second-line therapy success

  • Patients responding to ciclosporin should be transitioned to a thiopurine (azathioprine or mercaptopurine) at 3 months, unless they have previously failed adequate thiopurine therapy.
  • Patients responding to second-line therapy, who have failed thiopurine therapy, should be considered for long-term therapy with proven alternative drugs.

Second-line therapy failure

  • Surgery is the recommended course of action rather than considering switching between second-line therapies.
  • CT abdomen if considering surgery.

Prophylaxis and infections

PCP prophylaxis

  • Should be used in patients on triple immunosuppression, eg, steroid (prednisolone >20mg daily or equivalent) PLUS thiopurine PLUS infliximab.
  • Co-trimoxazole: 960mg 3 times per week, or 480mg once daily, or alternative if allergic.

CMV

  • If this is found it should be treated with:
  • IV ganciclovir: 5mg/kg twice daily for 3 to 5 days
  • Then oral valganciclovir, 900mg twice daily for 14 to 21 days.
  • Note: dose adjustments are required in CrCl <60mL/min. Please confirm with ward pharmacist or Renal Drug Database (log in required). 

Further information for health care professionals

Patient and self management information

ABBREVIATIONS

  • AXR: Abdominal x-ray
  • BP: Blood pressure 
  • CMV IgG: Cytomegalovirus immunoglobulin G
  • CRP: C-reactive protein
  • CT: Computed tomography 
  • CXR: Chest x-ray
  • EBV IgG: Epstein-Barr virus immunoglobulin G
  • EDTA: Ethylenediaminetetraacetic acid
  • FBC: Full blood count
  • HBV: Hepatitis B virus
  • HCV: Hepatitis C virus
  • HIV: Human immunodeficiency virus 
  • IBS: Irritable bowel syndrome
  • LFTs: liver function test
  • Mg2+: Magnesium ions
  • NSAIDS: Non-steroidal anti-inflammatory drugs
  • PCP: Pneumocystis pneumonia
  • TB: Tuberculosis
  • TGN: Trigeminal neuralgia
  • TPMT: Thiopurine methyltransferase
  • UC: Ulcerative colitis
  • U+Es: Urea and electrolytes
  • VZ IgG: Varicella-Zoster immunoglobulin G
  • 5-ASA: 5-aminosalicylic acids

Editorial Information

Last reviewed: 13/09/2024

Next review date: 31/10/2027

Author(s): Inflammatory Bowel Disease Team, Gastroenterology.

Version: 1

Approved By: TAM subgroup of the ADTC

Reviewer name(s): Dr C Fraser, Consultant Gastroenterologist.

Document Id: TAM657