Management of a hospitalized child or adolescent with acute severe ulcerative colitis

anti-TNF: anti-tumor necrosis factor; IV: intravenous; JAK: Janus kinase.

* Supportive care consists of hydration; nutrition; and management of pain, anemia, or hypoalbuminemia, as needed.

¶ Children who respond well to an initial course of IV glucocorticoids are typically weaned to oral glucocorticoids while adding a maintenance agent. For details, refer to UpToDate content on management of mild to moderate ulcerative colitis in children.

Δ Counseling for patients/families on medical rescue therapy versus colectomy:

• Surgery:
  • Improves symptoms most quickly because it removes the diseased colon.
  • After surgery, most patients will have an ileostomy for at least 3 months and can subsequently choose to proceed to a J-pouch.
  • After J-pouch surgery, most patients have bowel movements several times a day.
  • After surgery, some people have problems with inflammation in the pouch or incontinence, which can be treated. Some women may have reduced fertility.
  • Surgery eliminates the long-term risk for colon cancer and the need for frequent colonoscopies to monitor for colon cancer.
• Medical rescue therapy:
  • Approximately 75% respond at least temporarily, but approximately one-half of these people will lose response by 1 year. They will need to move on to colectomy or to one of the second-line options below.
  • These drugs suppress the immune system and require monitoring for safety.
  • These drugs are expensive. They are usually covered by medical insurance.
• Second-line medical options:
  • These medications sometimes work (tofacitinib, upadacitinib), but we don't really know how often.
  • Most of the information about effectiveness and risks of these therapies is from studies in nonhospitalized adults with ulcerative colitis.
  • Insurance does not always pay for these drugs.

◊ The majority of centers in the United States utilize infliximab as first-line rescue therapy in acute severe colitis due to ease of use. However, evidence suggests that calcineurin inhibitors have comparable efficacy^[1] and there is extensive experience with calcineurin inhibitors in both pediatric and adult centers.

§ Limited data exist in support of JAK inhibitors (tofacitinib, upadacitinib) in acute severe colitis. These are off-label uses in pediatric patients. The choice depends on clinician experience with the agent and considerations of their toxicities, based on indirect evidence from adult studies in acute severe colitis^[2]. Another option for this stage is changing from infliximab to a calcineurin inhibitor and vice versa. Sequential use of immunosuppressive agents may increase the risk of infection, but overall risks are generally acceptable, based primarily on indirect evidence from adults with inflammatory bowel disease or children with autoimmune diseases.