Download Ulcerative colitis

D. Turner · A.S. Day
Inflammatory bowel disease
Ulcerative colitis
Ulcerative colitis
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Assessment of disease activity Remission
(PUCAI <10 points) Mild to mild-to-moderate
disease
(PUCAI 10–45 points) Maintenance therapy with
5-ASA for all patients
50–70 mg/kg/day up to 4 g daily
in 2 divided doses 5-ASA 70 mg/kg/day
up to 4.8 g daily
in 2 divided doses Response
No response
Enemas of 5-ASA
(or steroids if intolerant
of 5-ASA) used as adjuvant
for both left-sided and
extensive colitis should
be offered
Moderate-to-severe to
severe disease
(PUCAI 50–85 points) Prednisone 1 mg/kg once daily
up to 40 mg + 5-ASA
70–80 mg/kg/day up to 4.8 g daily
in 2 divided doses Response
No response
Taper corticosteroids
over 8–10 weeks
Admission for
i.v. methylprednisolone
1–1.5 mg/kg up to 40–60 mg
in 2 divided doses
If disease is chronically active or
there are frequent flares, add
thiopurines (azathioprine ~2–2.5 mg/kg
once a day or 6-mercaptopurine
1–1.5 mg/kg once a day) If disease is still chronically
active or there are frequent flares
despite adequate thiopurine
treatment, consider
anti-TNF therapy (infliximab
or adalimumab) Response
Response
No response
with 3–5 days Consider second-line therapy
based on the PUCAI score
(cyclosporine, tacrolimus,
infliximab or colectomy) Downloaded by:
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Exacerbation
Medical therapies in IBD should be divided into those that induce remission (5-ASA, corticosteroids, anti-TNF therapy, and
likely probiotics) and those that maintain remission (5-ASA,
thiopurines, anti-TNF therapy, and likely probiotics).
— In any state of active disease, the following must be ruled
out: infectious colitis and Clostridium difficile, 5-ASA-related
colitis, and wrong diagnosis (e.g. immune deficiency, chronic
granulomatous disease, or Behcet’s disease).
— In children, endoscopic evaluation of the rectal mucosa is
conceived to be too invasive for repeated monitoring of disease
activity and response to therapy. Therefore, reliance on noninvasive indirect markers of disease activity should be used at
most visits. The Pediatric UC activity index (PUCAI) was developed for the use in children and has proved to be highly correlated with the endoscopic appearance of the colonic mucosa.
Cutoff values for remission and mild, moderate, and severe disease activity have been previously validated in two independent
pediatric cohorts. Endoscopic evaluation of the colonic mucosa
is indicated before major treatment changes, when the clinical
presentation is in question and during acute severe exacerbation not responding to intravenous steroid therapy.
— Recent data in adults suggest that 3 g Pentasa once a day
is superior to a dose administered twice a day.
— In high-risk patients (such as those presenting with se
vere colitis, especially at a young age), thiopurine may be considered for maintenance therapy at onset.
— In clinical practice, a dose of up to 100 mg/kg is often
Selected reading
used effectively but without solid evidence.
— In cases resistant to the newer 5-ASA regimes (e.g. Asa
col, Pentasa, Rafassal), it may be beneficial to switch to sulfasalazine that may be more effective but is also associated with
a higher adverse event rate (e.g. hypersensitivity, headache, GI
side effects, or azoospermia). A gradual dose increase over 7–14
days may decrease the adverse event rate.
— Measurement of TPMT (genotyping or enzymatic activity)
at baseline and after 2–3 months also of 6-TG and 6-MMP levels
may aid in optimizing thiopurine dosing.
— According to pediatric cohorts, PUCAI >45 points at day 3
warrants preparation for second-line therapy (cyclosporine,
infliximab, or colectomy) and >65–70 points at day 5 warrants
execution of the planned therapy. Those children not meeting
these cutoff values may be slow responders and should be
treated with corticosteroids for 2–5 more days until a decision
is made.
— Level 1 evidence for using biologics in pediatric UC is
currently available for infliximab in patients with moderate to
severe disease but not in those hospitalized for acute severe
colitis.
— Colectomy should also be considered in chronically ac
tive, resistant disease and in cases of complications (e.g. toxic
megacolon, dysplasia, or uncontrolled bleeding).
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al: Appraisal of the pediatric ulcerative colitis activity index
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Turner D, Otley AR, Mack D, de Bruijne J, Uusoue K, Walter T,
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Inflammatory bowel disease
D. Turner · A.S. Day
Ulcerative colitis
Downloaded by:
Verlag S. KARGER AG BASEL
172.16.7.165 - 4/9/2014 12:24:27 PM
65