Subacute: moderately to severely active ulcerative colitis that would normally be managed in an outpatient setting and does not require hospitalisation
Investigation
FBC
ESR
Management
Mild to Moderate UC Inducing Remission – STEP 1
Proctitis and Procto-sigmoiditis: Topical amino-salicyclate (Mesalazine) suppository or enema +/- PO, if cannot tolerate then topical cortico-steroid or oral Prednisolone accounting for patient preference
Left sided or extensive UC: high dose amino-salicyclate (Mesalazine) PO +/- topical amino-salicyclate or Beclometasone Dipropionate accounting for patient preference
Mild to Moderate UC Inducing Remission – STEP 2
If no improvement in 4 weeks consider adding Prednisolone PO to amino-salicyclate. Stop Beclometasone Dipropionate if adding oral prednisolone
Acute Severe UC (all extents) – STEP 1
IV Cortico-steroids and assess whether needs surgery
If cannot tolerate / declines IV Cortico-steroids then consider Ciclosporin (Immunosuppressant) or surgery
Acute Severe UC (all extents) – STEP 2
Consider adding intravenous Ciclosporin to intravenous corticosteroids or consider surgery for people who have little or no improvement within 72 hours, or worsen on steroids
Infliximab – See NICE technology appraisal CG163
Surgery Indicated if:
Stool frequency > 8 day
Pyrexia
Tachycardia
X-ray showing colonic dilatation
Maintaining Remission
Proctitis and Procto-sigmoiditis: amino-salicyclate topical +/- PO daily or intermittent
Left sided or extensive UC: amino-salicyclate PO daily or intermittent
Consider oral Azathioprine or oral Mercaptopurine to maintain remission after two or more inflammatory exacerbations in 12 months, and not maintained by ASA OR single episode or acute severe UC
