Ulcerative colitis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

acute severe ulcerative colitis

1st line – hospital admission + intravenous corticosteroid

Back

1st line –

hospital admission + intravenous corticosteroid

Acute severe UC (ASUC) in adults is defined as ≥6 bloody stools per day with at least one of the following symptoms: temperature >100.0ºF (37.8ºC), pulse >90 beats per minute, hemoglobin <10.5 g/dL (<105 g/L), erythrocyte sedimentation rate (ESR) >30 mm/h or C-reactive protein (CRP) >30 mg/L.[46][47] CRP ≥12 mg/L has been suggested as a sensitive cutoff for determining UC severity.[31]

These patients should be admitted to hospital for assessment and intensive management.[23][47][48]

Patients presenting with possible ASUC should have urgent inpatient assessment and blood tests (complete blood count, CRP, blood urea nitrogen and electrolytes, liver function tests, and serum magnesium level), stool culture, Clostridium difficile assay, radiologic imaging (abdominal x-ray or computed tomography), and flexible sigmoidoscopy.[23]

A high-dose intravenous corticosteroid such as methylprednisolone or hydrocortisone is recommended first line to induce remission in patients with ASUC.[23][46][47][48]

Primary options

hydrocortisone sodium succinate: 100 mg intravenously every 6 hours

methylprednisolone sodium succinate: 0.75 to 1 mg/kg intravenously once daily, maximum 60-80 mg/day

Plus – supportive measures

Back

Plus –

supportive measures

Treatment recommended for ALL patients in selected patient group

Patients may be hemodynamically unstable on admission, and need supportive measures such as blood transfusion, fluids, and electrolyte replacement.[47] Prophylactic low molecular weight heparin to prevent venous thromboembolism is recommended.[23][47]

Consider – cyclosporine or infliximab

Back

Consider –

cyclosporine or infliximab

Treatment recommended for SOME patients in selected patient group

If patients do not respond adequately to intravenous corticosteroid treatment within 3 days, rescue therapy with either intravenous infliximab or cyclosporine should be added to the corticosteroid.[23][46][47][48]

Although evidence indicates a comparable efficacy, the adverse effect profile of cyclosporine is less favorable than infliximab.[49][50]

There is growing interest in accelerated infliximab induction for acute severe UC (ASUC), but US guidance does not currently recommend accelerated infliximab induction for patients with ASUC.[23] The British Society of Gastroenterology recommends that patients treated with infliximab who have not responded to the first infusion sufficiently after 3-5 days should be treated with an accelerated induction regimen (i.e., an early repeat infusion), particularly in those with a low albumin (below 3.5 g/dL [35 g/L]) after colorectal surgical review to determine whether emergency colectomy is required.[33][47]

These alternative regimens are not detailed here.

Primary options

cyclosporine non-modified: 2 mg/kg intravenously once daily

infliximab: 5 mg/kg intravenously given at weeks 0, 2, and 6 initially, followed by 5 mg/kg every 8 weeks

2nd line – surgery

Back

2nd line –

surgery

Any patients with severe intractable symptoms or intolerable medicine adverse effects should be considered for colectomy.[47][48]

In acute severe UC (ASUC), delay in surgery is associated with an increased risk of surgical complications.[23][48]

The absolute indications for colectomy for patients with ASUC are complications such as toxic megacolon, perforation, uncontrolled severe hematochezia, or multiorgan dysfunction.[23][47][48]

moderate-to-severe disease

1st line – oral corticosteroid

Back

1st line –

oral corticosteroid

Oral systemic corticosteroids can be used to induce remission in patients with moderate to severely active UC of any extent and have typically been first-line induction treatments in moderate-to-severe disease.[23][24][48]

In patients with moderately active UC, oral budesonide multi-matrix system (MMX), a locally acting corticosteroid, can be considered before the use of systemic therapy.[23]

Taper dose gradually once remission is induced.

Primary options

prednisone: 40-60 mg orally once daily

budesonide: 9 mg orally (extended-release/prolonged-release) once daily in the morning

1st line – biologic agent

Back

1st line –

biologic agent

In patients with moderate-to-severe UC, early use of biologic treatment with or without immunosuppressant therapy, rather than gradual step-up treatment after aminosalicylate failure, is suggested.[46] However, patients with less severe disease may prefer gradual step-up therapy.[46]

Patients with less severe disease may prefer to begin with tumor necrosis factor (TNF)-alpha inhibitor monotherapy, but this increases the risk of drug antibody formation.[46]

Combination treatment with a TNF-alpha inhibitor, vedolizumab, or ustekinumab plus a thiopurine or methotrexate is suggested rather than biologic monotherapy.[46][47] Monotherapy with a TNF-alpha inhibitor, vedolizumab, ustekinumab, or tofacitinib is preferred to monotherapy with a thiopurine.[46] Mirikizumab is now also approved for use in these patients, but American Gastroenterological Association (AGA) guidelines do not currently recommend its use.

Adalimumab is recommended for inducing and sustaining clinical remission in adult patients with moderate-to-severe active UC who have had an inadequate response to immunosuppressants such as corticosteroids, azathioprine, or mercaptopurine.[23][46] Meta-analyses report that adalimumab is more effective than placebo with respect to inducing clinical response, clinical remission, and mucosal healing.[53][54]

Golimumab is recommended for inducing and sustaining clinical remission in adult patients with moderate-to-severe active UC who have had an inadequate response to immunosuppressants such as corticosteroids, azathioprine, or mercaptopurine.[23][46] Golimumab has been shown to induce clinical remission and mucosal healing in patients with moderate-to-severe active UC with a similar safety profile to other TNF-alpha inhibitors.[55][56]

Infliximab is effective as long-term maintenance therapy for UC and it should be considered as an alternative to induce and maintain disease remission.[57][58] When infliximab is used as induction therapy for patients with moderate to severely active UC, combination therapy with azathioprine is recommended.[23][47] In patients with moderate-to-severe UC who are naive to biologic agents, the AGA suggests using infliximab rather than adalimumab, for induction of remission.[46]

Vedolizumab is approved to treat moderate to severely active UC. It has been shown to be more effective than placebo as induction and maintenance therapy for UC.[59][60] One Cochrane review found vedolizumab to be more effective than placebo for inducing clinical remission, clinical response, and endoscopic remission in patients with moderate-to-severe active UC, and for preventing relapse in patients with quiescent UC.[61] In another systematic review and meta-analysis, vedolizumab efficacy for the induction and maintenance of mucosal healing in UC was similar to that of TNF-alpha inhibitors.[62] Network meta-analysis suggested that vedolizumab may lead to a more sustained clinical response than other biologic agents approved for UC.[53] Vedolizumab appears to have a favorable safety profile.[63] The AGA recommends vedolizumab in preference to adalimumab, for the treatment of patients with moderate-to-severe UC who are naive to biologic agents for induction of remission.[46] The American College of Gastroenterology recommends vedolizumab for induction of remission for patients who have previously failed TNF-alpha inhibitor therapy.[23] The AGA suggests vedolizumab in combination with a thiopurine or methotrexate rather than thiopurine monotherapy.[46]

Ustekinumab is approved for the treatment of adults with moderate to severely active UC. The AGA recommends ustekinumab, rather than vedolizumab or adalimumab for induction of remission in patients with moderate-to-severe UC who have previously been exposed to infliximab, particularly those with primary nonresponse.[46] Patients with less severe disease may prefer vedolizumab as a potentially safer alternative.[46] The AGA suggests that ustekinumab is given in combination with a thiopurine or methotrexate rather than thiopurine monotherapy.[46] The interim results of one phase 3 study (UNIFI trial) of ustekinumab in biologic-naive and biologic-experienced adults with moderate to severely active UC reported that ustekinumab is more effective than placebo for inducing and maintaining remission. In addition, significantly more patients treated with ustekinumab achieved endoscopic improvement and mucosal healing.[64][65]

Mirikizumab, a monoclonal antibody targeting IL-23, is approved for the treatment of adults with moderately to severely active UC. Mirikizumab is the only approved UC treatment that selectively targets the p19 subunit of IL-23, which plays a role in inflammation related to UC. In two phase 3, randomized, doouble-blind, placebo controlled trials it was found that mirikizumab was more effective than placebo in inducing and maintaining clinical remission in patients with moderately to severely active UC.[52] US guidelines do not currently include recommendations on mirikizumab as it is a relatively new treatment.

To optimize drug concentration and clinical improvement for patients with UC being treated with immunosuppressants and/or biologics, therapeutic drug monitoring (TDM) is becoming more frequently used to check drug trough concentration, and assess for the presence of antidrug antibodies.[89][90][91] BMJ Rapid Recommendations: proactive therapeutic drug monitoring of biologic drugs in adult patients with inflammatory bowel disease, inflammatory arthritis, or psoriasis: a clinical practice guideline Opens in new window TDM can be performed at any point during induction or maintenance therapy, and is conditionally recommended by the AGA to guide treatment changes for patients with inflammatory bowel disease.[89][92]

Primary options

infliximab: 5 mg/kg intravenously given at weeks 0, 2, and 6 initially, followed by 5 mg/kg every 8 weeks

adalimumab: 160 mg subcutaneously at week 0, then 80 mg at week 2, followed by 40 mg every other week starting at week 4

golimumab: 200 mg subcutaneously at week 0, then 100 mg at week 2, followed by 100 mg every 4 weeks starting at week 6

vedolizumab: 300 mg intravenously given at weeks 0, 2, and 6 initially, followed by 300 mg every 8 weeks

ustekinumab: body weight ≤55 kg: 260 mg intravenously as a single dose, followed by 90 mg subcutaneously every 8 weeks (starting 8 weeks after the initial dose); body weight 56-85 kg: 390 mg intravenously as a single dose, followed by 90 mg subcutaneously every 8 weeks (starting 8 weeks after the initial dose); body weight ≥85 kg: 520 mg intravenously as a single dose, followed by 90 mg subcutaneously every 8 weeks (starting 8 weeks after the initial dose)

Secondary options

mirikizumab: 300 mg intravenously given at weeks 0, 4, and 8 initially, followed by 200 mg subcutaneously every 4 weeks

Consider – immunosuppressant

Back

Consider –

immunosuppressant

Treatment recommended for SOME patients in selected patient group

A thiopurine (e.g., azathioprine, mercaptopurine) or methotrexate in combination with vedolizumab or ustekinumab is recommended for induction of remission in patients with moderate-to-severe UC.[23][46][47]

When infliximab is used as induction therapy, it should be given in combination with azathioprine.[23][47]

Dose-dependent adverse effects of methotrexate include bone marrow suppression, particularly leukopenia, which can develop suddenly and have an unpredictable course; liver injury; and infections.[66] Other adverse effects (not dose-dependent) include pancreatitis, headache, fatigue, anorexia, weight loss, stomatitis, alopecia, arthralgia, muscular weakness, and rash.[66]

Thiopurine therapy is associated with a small but statistically significant risk increase for lymphoma among adults with inflammatory bowel disease compared with patients not receiving thiopurine.[67] Persistent use of thiopurine is associated with an increased risk of nonmelanoma skin cancer; therefore, patients should be educated in primary skin cancer prevention (e.g., reduced ultraviolet exposure).[68]

Azathioprine may be considered in pregnancy, but should only be initiated under specialist guidance.[69][70]

Azathioprine and mercaptopurine doses should be lowered in patients with heterozygous thiopurine methyltransferase variant genotype.[71]

Allopurinol should be avoided (or patients monitored closely) in patients taking thiopurines, as it inhibits the breakdown of azathioprine and increases the risk of myelosuppression.[72] However, adjunctive treatment with low-dose allopurinol, in addition to a 25% to 50% thiopurine dose reduction, is required for select patients in whom thiopurine is preferentially metabolized via the hepatotoxic methylmercaptopurine pathway.[73][74][75]

Monotherapy with either a thiopurine or methotrexate is not recommended for induction therapy.[23][46]

Primary options

azathioprine: 2 to 2.5 mg/kg/day orally

mercaptopurine: 1.5 mg/kg/day orally

methotrexate: consult specialist for guidance on dose

2nd line – Janus kinase (JAK) inhibitor

Back

2nd line –

Janus kinase (JAK) inhibitor

Tofacitinib is approved for the treatment of moderate to severely active UC. Phase 3 randomized controlled trials (RCTs) have demonstrated that tofacitinib is superior to placebo for the induction and maintenance of remission of moderate to severely active UC (Mayo score 6-12) in patients previously treated with conventional therapy or a TNF-alpha inhibitor.[79] [ ] Network meta-analyses have shown that tofacitinib is noninferior to TNF-alpha inhibitors in biologic-naive patients, and suggest that it is the most effective second-line agent in patients with previous biologic failure.[80][81]

Upadacitinib is approved for the treatment of adults with moderately to severely active UC. Data from three phase 3 RCTs show clinical remission at 8 weeks (primary end point) with upadacitinib (26% and 34%) compared with placebo (5% and 4%, respectively) and at 52 weeks (42% or 52%, depending on the dose of upadacitinib compared with placebo 12%).[82][83] One recent systematic review suggested that upadacitinib was the best performing agent for the induction of clinical remission compared with other biologics and small molecule drugs; however, it was also the worst performing agent in terms of adverse effects.[84]

The US Food and Drug Administration (FDA) has issued a warning about an increased risk of serious cardiovascular events, malignancy, thrombosis, and death with JAK inhibitors.[85] This follows final results from a large randomized safety clinical trial which compared tofacitinib with TNF-alpha inhibitors in patients with rheumatoid arthritis. The study found an increased risk of blood clots and death with the lower dose of tofacitinib (5 mg twice daily); this serious event had previously been reported only with the higher dose (10 mg twice daily - the induction dose for UC) in the preliminary analysis.[86]

The FDA advises clinicians to reserve JAK inhibitors for patients who have had an inadequate response or are intolerant to one or more TNF-alpha inhibitors and to consider the patient’s individual benefit-risk profile when deciding to prescribe or continue treatment with these medications, particularly in patients who are current or past smokers, patients with other cardiovascular risk factors, those who develop a malignancy, and those with a known malignancy (other than a successfully treated nonmelanoma skin cancer).[85]

The European Medicines Agency (EMA) also recommends measures to minimize the risk of serious adverse effects with JAK inhibitors in patients who are >65 years old, patients who are current or past smokers, patients with other cardiovascular risk factors, and patients with other malignancy risk factors. The EMA advises that JAK inhibitors should only be used to treat moderate or severe UC in these patient groups if no suitable treatment alternative is available. In addition the EMA recommends that: JAK inhibitors should be used with caution in patients at high risk of blood clots (other than those listed above); and the dose should be reduced in patients who are at risk of venous thromboembolism, major cardiovascular problems, or cancer, where possible.[87] The UK Medicines and Healthcare products Regulatory Agency (MHRA) supports these recommendations, and also advises patients taking JAK inhibitors to carry out periodic skin examinations, due to an increased risk of nonmelanoma skin cancer associated with these medications.[88]

Guidelines recommend tofacitinib for induction of remission in patients with moderate-to-severe UC who have previously been exposed to infliximab, particularly those with primary nonresponse, or those who are intolerant to TNF-alpha inhibitor therapy.[23][46] Upadacitinib is now also approved for use in these patients, but American Gastroenterological Association guidelines do not currently recommend its use.

Primary options

tofacitinib: induction: 10 mg orally (immediate-release) twice daily or 22 mg orally (extended-release) once daily for at least 8 weeks, then transition to maintenance therapy depending on response, may be continued for a maximum of 16 weeks depending on response; maintenance: 5 mg orally (immediate-release) twice daily or 11 mg orally (extended-release) once daily

upadacitinib: induction: 45 mg orally once daily for 8 weeks, then transition to maintenance therapy depending on response; maintenance: 15-30 mg orally once daily

2nd line – sphingosine 1-phosphate (S1P) receptor modulator

Back

2nd line –

sphingosine 1-phosphate (S1P) receptor modulator

S1P receptor modulators (e.g., ozanimod, etrasimod) are approved for the treatment of adults with moderately to severely active UC. However, the US guidelines do not recommend their use as yet.

One pivotal phase 3 randomized controlled trials (RCTs) evaluating ozanimod as an induction and maintenance therapy versus placebo in adult patients with moderately to severely active UC found that during the induction at week 10 (ozanimod n=429 vs. placebo n=216), 18% of patients receiving ozanimod achieved clinical remission (primary end point) compared with 6% of patients in the placebo group. During maintenance at week 52 (ozanimod n=230 vs. placebo n=227), 37% of patients receiving ozanimod maintained clinical remission compared with 19% of patients in the placebo group (clinical remission is defined as: rectal bleeding subscore = 0, stool frequency subscore = 0 or 1 (and a decrease from baseline in the stool frequency subscore of ≥1 point), and endoscopy subscore = 0 or 1 without friability). The study met secondary end points such as clinical response (defined as as a reduction from baseline in the 3-component Mayo score of ≥2 points and ≥35%, and a reduction from baseline in the rectal bleeding subscore of ≥1 point or an absolute rectal bleeding subscore of 0 or 1) and endoscopic improvement (defined as a Mayo endoscopy subscore of 0 or 1 without friability) for both induction and maintenance.[76]

The safety and efficacy of etrasimod in patients with moderately to severely active UC has been demonstrated in two RCTs.[77][78]

These drugs are contraindicated in patients with recent (in the last 6 months) myocardial infarction, unstable angina, stroke, transient ischemic attack, or heart failure.[25] They are also contraindicated in patients with a history or presence of second- or third-degree atrioventricular block, sick sinus syndrome, or sino-atrial block (unless the patient has a functioning pacemaker).

Primary options

ozanimod: 0.23 mg orally once daily for 4 days, followed by 0.46 mg once daily for 3 days, then 0.92 mg once daily thereafter

etrasimod: 2 mg orally once daily

3rd line – colectomy

Back

3rd line –

colectomy

Any patients with severe intractable symptoms or intolerable medicine adverse effects should be considered for colectomy.[23][46][47][48]

One systematic review of outcomes and postoperative complications following colectomy for patients with UC suggests that early and late complications arise in about one third of patients undergoing surgery for UC.[93] While colorectal surgical procedures are recommended for a specific group of patients, the postoperative complications associated with these procedures should not be underestimated.[93]

mild disease

proctitis

1st line – topical (rectal) aminosalicylate

Back

1st line –

topical (rectal) aminosalicylate

First-line treatment to induce remission for patients with mildly active ulcerative proctitis is a topical (rectal) aminosalicylate.[7][23][47][48]

Mesalamine is the only aminosalicylate available as a topical formulation.

Primary options

mesalamine rectal: (4 g/60 mL enema) 4 g rectally once daily at bedtime; (suppository) 1 g rectally once daily at bedtime

left-sided colitis

1st line – oral aminosalicylate plus topical (rectal) aminosalicylate

Back

1st line –

oral aminosalicylate plus topical (rectal) aminosalicylate

First-line treatment for the induction of remission in patients with left-sided colitis is a rectal aminosalicylate (in preference to a rectal corticosteroid) combined with an oral aminosalicylate.[7][23][47][48]

Aminosalicylates include mesalamine, sulfasalazine, balsalazide, and olsalazine. Mesalamine is the only aminosalicylate available as a topical formulation.

Primary options

mesalamine: oral dose depends on brand used; consult product literature for guidance on dose

balsalazide: 2250 mg orally three times daily

sulfasalazine: 1 g orally every 6-8 hours initially, titrate according to response, usual dose 0.5 g every 6 hours, maximum 6 g/day

-- AND --

mesalamine rectal: (4 g/60 mL enema) 4 g rectally once daily at bedtime; (suppository) 1 g rectally once daily at bedtime

Secondary options

olsalazine: 500 mg orally twice daily

and

mesalamine rectal: (4 g/60 mL enema) 4 g rectally once daily at bedtime; (suppository) 1 g rectally once daily at bedtime

Consider – oral budesonide

Back

Consider –

oral budesonide

Treatment recommended for SOME patients in selected patient group

For patients with mildly active left-sided UC who are intolerant or nonresponsive to oral and rectal aminosalicylate, the addition of oral budesonide multi-matrix system (MMX) is recommended for induction of remission.[7][23][47][48]

Second-generation corticosteroids, such as budesonide MMX, are starting to emerge as a primary treatment option in mild-to-moderate UC.[47][94][95] They are associated with significantly fewer corticosteroid-related adverse events than conventional corticosteroids.[96] MMX technology may facilitate adherence by reducing the pill burden.[97]

Primary options

budesonide: 9 mg orally (extended-release/prolonged-release) once daily in the morning

extensive colitis

1st line – oral aminosalicylate

Back

1st line –

oral aminosalicylate

The American College of Gastroenterology suggests that an oral aminosalicylate is the preferred treatment.[23]

Primary options

mesalamine: oral dose depends on brand used; consult product literature for guidance on dose

balsalazide: 2250 mg orally three times daily

sulfasalazine: 1 g orally every 6-8 hours initially, titrate according to response, usual dose 0.5 g every 6 hours, maximum 6 g/day

Secondary options

olsalazine: 500 mg orally twice daily

Consider – oral corticosteroid

Back

Consider –

oral corticosteroid

Treatment recommended for SOME patients in selected patient group

In patients with mild UC refractory to optimized oral and rectal aminosalicylate therapy, the addition of either oral prednisone or budesonide multi-matrix system (MMX) is recommended.[23][47]

Second-generation corticosteroids, such as budesonide MMX, are starting to emerge as a primary treatment option in mild-to-moderate UC.[94][95] They are associated with significantly fewer corticosteroid-related adverse events than conventional corticosteroids.[96] MMX technology may facilitate adherence by reducing the pill burden.[97]

Primary options

prednisone: 5-60 mg/day orally given as a single dose or in divided doses

budesonide: 9 mg orally (extended-release/prolonged-release) once daily in the morning

ONGOING

disease in remission

acute severe ulcerative colitis

1st line – infliximab or thiopurine

Back

1st line –

infliximab or thiopurine

The goal of maintenance therapy is to maintain corticosteroid-free clinical and endoscopic remission; systemic corticosteroids are not recommended for maintenance of remission of UC of any severity.[23][47]

The choice of drug for maintenance therapy depends on the drug used for induction of remission.

Patients with acute severe UC (ASUC) who achieve remission with infliximab treatment should continue treatment with the same agent for maintenance of remission.[23][47]

If patients with ASUC achieve remission with cyclosporine, thiopurines are suggested for maintenance of remission.[23][47]

Thiopurine therapy is associated with a small but statistically significant risk increase of lymphoma among adults with inflammatory bowel disease compared with patients not on thiopurine therapy.[67] There is also an increased risk of nonmelanoma skin cancer; therefore, patients should be educated in primary skin cancer prevention (e.g., reduced ultraviolet exposure).[68]

Azathioprine may be considered in pregnancy, but should only be initiated under specialist guidance.[69][70]

Azathioprine and mercaptopurine doses should be lowered in patients with heterozygous thiopurine methyltransferase variant genotype.[71]

Induction and maintenance doses are detailed here. However, if a patient has already been started on a particular treatment, continue treatment at the maintenance dose.

Primary options

infliximab: 5 mg/kg intravenously given at weeks 0, 2, and 6 initially, followed by 5 mg/kg every 8 weeks

azathioprine: 2 to 2.5 mg/kg/day orally

mercaptopurine: 1.5 mg/kg/day orally

moderate-to-severe disease

1st line – individualized maintenance therapy

Back

1st line –

individualized maintenance therapy

The American Gastroenterological Association guidelines on treatments for moderate-to-severe UC do not present separate recommendations for induction and maintenance of remission.[46] It is assumed that if a drug (excluding corticosteroids and cyclosporine) is effective for induction of remission, it will be continued for maintenance of remission unless otherwise specified.[46][47]

There are some exceptions and additional considerations to be aware of.

Patients with previous moderate-to-severe UC who have achieved remission with TNF-alpha inhibitors and/or immunosuppressants, or JAK inhibitors, should not be given concomitant aminosalicylates for maintenance of remission.[23][46]

For patients with previously moderate-to-severe UC who achieve remission with corticosteroid induction, a thiopurine (e.g., azathioprine, mercaptopurine) is suggested for maintenance of remission in preference to no treatment.[46] Methotrexate monotherapy is not recommended for maintenance of remission.[23][46]

mild disease: proctitis

1st line – topical (rectal) mesalamine

Back

1st line –

topical (rectal) mesalamine

In patients with mildly active ulcerative proctitis, a rectal aminosalicylate is recommended to maintain remission.[7][23][47][48]

The large majority of patients with mild UC who achieve remission with aminosalicylate therapy continue with aminosalicylate treatment to maintain remission.[23][47]

Primary options

mesalamine rectal: (4 g/60 mL enema) 4 g rectally once daily at bedtime; (suppository) 1 g rectally once daily at bedtime

2nd line – treatment escalation

Back

2nd line –

treatment escalation

Patients on maintenance therapy with a high-dose aminosalicylate, who require two or more courses of corticosteroids in 12 months, or who become corticosteroid dependent or refractory, require treatment escalation to a thiopurine, a TNF-alpha inhibitor, vedolizumab, or tofacitinib.[33][47] The treatment choice should be determined by clinical factors and patient preference.[33]

mild disease: left-sided or extensive colitis

1st line – oral aminosalicylate

Back

1st line –

oral aminosalicylate

In patients with mildly active left-sided or extensive UC, an oral aminosalicylate is recommended to maintain remission.[7][23][47][48]

Primary options

mesalamine: oral dose depends on brand used; consult product literature for guidance on dose

balsalazide: 2250 mg orally three times daily

sulfasalazine: 1 g orally every 6-8 hours initially, titrate according to response, usual dose 0.5 g every 6 hours, maximum 6 g/day

Secondary options

olsalazine: 500 mg orally twice daily

Use of this content is subject to our disclaimer

Ulcerative colitis

Treatment algorithm

acute severe ulcerative colitis

hospital admission + intravenous corticosteroid

Primary options

supportive measures

cyclosporine or infliximab

Primary options

surgery

moderate-to-severe disease

oral corticosteroid

Primary options

biologic agent

Primary options

Secondary options

immunosuppressant

Primary options

Janus kinase (JAK) inhibitor

Primary options

sphingosine 1-phosphate (S1P) receptor modulator

Primary options

colectomy

mild disease

topical (rectal) aminosalicylate

Primary options

oral aminosalicylate plus topical (rectal) aminosalicylate

Primary options

Secondary options

oral budesonide

Primary options

oral aminosalicylate

Primary options

Secondary options

oral corticosteroid

Primary options

disease in remission

infliximab or thiopurine

Primary options

individualized maintenance therapy

topical (rectal) mesalamine

Primary options

treatment escalation

oral aminosalicylate

Primary options

Secondary options