Inpatient management for adult patients with severe ulcerative colitis

IV: intravenous.
* Supportive care includes monitoring vital signs and stool output, intravenous fluid and electrolyte replacement, and venous thromboembolism prophylaxis.
¶ Options for IV glucocorticoids include methylprednisolone and hydrocortisone. We prefer methylprednisolone and administer IV glucocorticoids as intermittent, bolus doses rather than a continuous infusion.
Δ We use topical glucocorticoid therapy for severe disease involving the distal colon to help provide symptomatic relief (eg, reduced fecal urgency).
◊ Glucocorticoids are not used for long-term maintenance therapy. Options for maintenance therapy include an anti-tumor necrosis factor agent (eg infliximab) with or without a thiopurine or thiopurine monotherapy.
§ The efficacy and safety of infliximab and cyclosporine appear comparable in this setting. We use infliximab for most hospitalized patients with glucocorticoid-refractory severe ulcerative colitis, but cyclosporine is an acceptable option depending on patient comorbidities and clinician preference. We avoid cyclosporine in patients with certain comorbidities, including hypertension, renal disease, and history of seizure disorder.
¥ For patients who do not respond to the initial infliximab infusion, the second infliximab dose is typically 10 mg/kg.
‡ Cyclosporine is used as a short-term bridge to maintenance therapy with a thiopurine. Prophylaxis against Pneumocystis jirovecii pneumonia should be given during cyclosporine therapy.
† For patients who respond to the first infliximab infusion, the next infusion is given in two weeks. For patients who respond to second infliximab infusion, the next infusion is given in four weeks. For most patients who respond to infliximab, a thiopurine is added to the drug regimen upon hospital discharge.