Extensive colitis

Extensive colitis

  • If not already performed, plan index colonoscopy once disease in remission to classify disease

  • Define schedule for surveillance, usually to commence 8-10 years after first symptoms

  • Consider 5-ASA as chemoprevention against cancer

  • Ensure vaccines updated

  • Provide patient education

  • Provide contact details in case of disease flare

Review treatment plan

ECCO statement 2B (UC 2017)

Disease severity influences treatment modality and route of administration [EL1]. Clinical indices of disease severity have not been adequately validated, although clinical, laboratory, imaging, and endoscopic parameters, including histopathology, impact on patients’ management [EL 2]. Remission is defined as stool frequency ≤ 3/day, no rectal bleeding, and normal mucosa at endoscopy [EL5]. Absence of a histological acute inflammatory infiltrate predicts quiescent course of disease [EL3]

Further information

Assess disease activity

Quiescent

Mild

Moderate

Severe

  • Treatment depends on disease duration and activity; previous disease course including extra-intestinal manifestations; and response and side-effects of medication

  • Maintenance therapy usually daily mesalazine ≥2 g PO

  • Determine follow-up schedule (e.g. on demand or in 6 months; sooner if recent moderate/severe disease)

Mesalazine

ECCO statement 11E (UC 2017)

Mild to moderately active extensive ulcerative colitis should initially be treated with an aminosalicylate enema 1 g/day [EL1] combined with oral mesalamine ≥ 2.4 g/day [EL1]. Once-daily dosing with mesalamine is as effective as divided doses [EL1]. Systemic corticosteroids are appropriate in patients with moderate to severe activity and in those with mild activity who do not respond to mesalamine [EL1]. Severe extensive colitis is an indication for hospital admission for intensive treatment [EL1]

Further information

  • Treatment depends on disease duration and activity; previous disease course including extra-intestinal manifestations; and response and side-effects of medication

  • Generally, treatment escalated if relapse occurs, or continues (e.g. > 1 month) on treatment, as follows: mesalazine PO -> mesalazine PO & enema -> add oral steroids

  • Determine follow-up schedule (e.g. 6 weeks)

Topical and oral mesalazine

ECCO statement 11E (UC 2017)

Mild to moderately active extensive ulcerative colitis should initially be treated with an aminosalicylate enema 1 g/day [EL1] combined with oral mesalamine ≥ 2.4 g/day [EL1]. Once-daily dosing with mesalamine is as effective as divided doses [EL1]. Systemic corticosteroids are appropriate in patients with moderate to severe activity and in those with mild activity who do not respond to mesalamine [EL1]. Severe extensive colitis is an indication for hospital admission for intensive treatment [EL1]

Further information

  • Treatment depends on disease duration and activity; previous disease course including extra-intestinal manifestations; and response and side-effects of medication

  • Generally, treatment escalated if relapse occurs, or continues (e.g. > 1 month) on treatment, as follows: mesalazine PO or enema -> mesalazine PO & enema -> add oral steroids

  • Plan maintenance therapy

  • Determine follow-up schedule (e.g. 3 weeks)

Topical and oral mesalazine

ECCO statement 11E (UC 2017)

Mild to moderately active extensive ulcerative colitis should initially be treated with an aminosalicylate enema 1 g/day [EL1] combined with oral mesalamine ≥ 2.4 g/day [EL1]. Once-daily dosing with mesalamine is as effective as divided doses [EL1]. Systemic corticosteroids are appropriate in patients with moderate to severe activity and in those with mild activity who do not respond to mesalamine [EL1]. Severe extensive colitis is an indication for hospital admission for intensive treatment [EL1]

Further information

  • Provide steroids and mesalazine both orally and topically

  • Response should occur within 2 weeks of starting oral steroids

  • Plan maintenance therapy

  • Determine follow-up schedule (e.g. 1-2 weeks)

Mesalazine & steroids. Consider need for hospital admission

  • Confirm relapse with flexible sigmoidoscopy (some patients can be treated empirically with dose escalation, depends on disease duration and activity, previous disease course including response and side-effects of medication)

  • Check stool culture, C. difficile assay (and parasites if travel history)

Reassess disease

Assess response

Assess response

ECCO statement 3G (UC 2017)

Microbial testing is recommended in patients with colitis relapse. This includes testing for C. difficile and Cytomegalovirus infection [EL3]

ECCO statement 11C (UC 2017)

Mild to moderately active left-sided ulcerative colitis should initially be treated with an aminosalicylate enema ≥ 1 g/day [EL1] combined with oral mesalamine ≥ 2.4 g/day [EL1], which is more effective than oral or topical aminosalicylates, or topical steroids alone [EL1]. Topical mesalamine is more effective than topical steroids [EL1]. Once-daily dosing with mesalamine is as effective as divided doses [EL1]

Further information

  • Treat based on disease activity and extent

  • Exclude C. difficile infection, especially in those hospitalised or who have received antibiotics recently

  • Consider flexible sigmoidoscopy and biopsy to assess response and exclude other diagnoses including CMV

  • Add thiopurine if relapse within 3 months of steroid-induced remission

Treatment based on activity / extent

ECCO statement 3G (UC 2017)

Microbial testing is recommended in patients with colitis relapse. This includes testing for C. difficile and Cytomegalovirus infection [EL3]

ECCO statement 11E (UC 2017)

Mild to moderately active extensive ulcerative colitis should initially be treated with an aminosalicylate enema 1 g/day [EL1] combined with oral mesalamine ≥ 2.4 g/day [EL1]. Once-daily dosing with mesalamine is as effective as divided doses [EL1]. Systemic corticosteroids are appropriate in patients with moderate to severe activity and in those with mild activity who do not respond to mesalamine [EL1]. Severe extensive colitis is an indication for hospital admission for intensive treatment [EL1]

Further information

  • Reassess disease activity with flexible sigmoidoscopy (some patients can be treated empirically with dose escalation, depends on disease duration and activity, previous disease course including response and side-effects of medication)

  • Screen colonic biopsies for CMV infection in treatment refractory disease

  • Exclude C. difficile infection if treatment refractory or following recent antibiotic use

  • Generally, treatment escalated if relapse occurs, or continues (e.g. > 1 month) on treatment, as follows: mesalazine PO -> mesalazine PO & enema -> add oral steroids. Some but not all studies suggest greater benefit from higher mesalazine doses (4.8 vs. 2.4 g/d)

Add oral steroids

ECCO statement 3G (UC 2017)

Microbial testing is recommended in patients with colitis relapse. This includes testing for C. difficile and Cytomegalovirus infection [EL3]

ECCO statement 11E (UC 2017)

Mild to moderately active extensive ulcerative colitis should initially be treated with an aminosalicylate enema 1 g/day [EL1] combined with oral mesalamine ≥ 2.4 g/day [EL1]. Once-daily dosing with mesalamine is as effective as divided doses [EL1]. Systemic corticosteroids are appropriate in patients with moderate to severe activity and in those with mild activity who do not respond to mesalamine [EL1]. Severe extensive colitis is an indication for hospital admission for intensive treatment [EL1]

Further information

  • Flexible sigmoidoscopy and biopsy to assess response and exclude other diagnoses including CMV

  • Exclude C. difficile infection

Sigmoidoscopy

Assess response

Continue treatment & reassess response

ECCO statement 11E (UC 2017)

Mild to moderately active extensive ulcerative colitis should initially be treated with an aminosalicylate enema 1 g/day [EL1] combined with oral mesalamine ≥ 2.4 g/day [EL1]. Once-daily dosing with mesalamine is as effective as divided doses [EL1]. Systemic corticosteroids are appropriate in patients with moderate to severe activity and in those with mild activity who do not respond to mesalamine [EL1]. Severe extensive colitis is an indication for hospital admission for intensive treatment [EL1]

ECCO statement 12D (UC 2017)

Options for a stepwise escalation of maintenance therapy include dose escalation of oral/rectal aminosalicylates [EL1], the addition of thiopurines [EL2], and anti-TNF therapy or vedolizumab [EL1]

ECCO statement 12I (UC 2017)

Anti-TNF or vedolizumab may be used as first-line biological therapy. Vedolizumab is effective in patients failing anti-TNF [EL2]. In patients responding to vedolizumab, maintenance therapy with vedolizumab is appropriate [EL2]

Further information

Escalate treatment

ECCO statement 3G (UC 2017)

Microbial testing is recommended in patients with colitis relapse. This includes testing for C. difficile and Cytomegalovirus infection [EL3]

ECCO statement 11C (UC 2017)

Mild to moderately active left-sided ulcerative colitis should initially be treated with an aminosalicylate enema ≥ 1 g/day [EL1] combined with oral mesalamine ≥ 2.4 g/day [EL1], which is more effective than oral or topical aminosalicylates, or topical steroids alone [EL1]. Topical mesalamine is more effective than topical steroids [EL1]. Once-daily dosing with mesalamine is as effective as divided doses [EL1]

Further information

  • Treat based on disease activity and extent

  • Exclude C. difficile infection, especially in those hospitalised or who have received antibiotics recently

  • Consider flexible sigmoidoscopy and biopsy to assess response and exclude other diagnoses including CMV

  • Add thiopurine if relapse within 3 months of steroid-induced remission

Treatment based on activity / extent

Consider need for admission to hospital

Maintenance of remission

Maintenance of remission

  • Treatment depends on disease duration and activity; previous disease course including extra-intestinal manifestations; and response and side-effects of medication

  • Maintenance therapy usually daily mesalazine ≥2 g PO

  • Determine follow-up schedule (e.g. on demand or in 6 months; sooner if recent moderate/severe disease)

Mesalazine

  • Confirm relapse with flexible sigmoidoscopy (some patients can be treated empirically with dose escalation, depends on disease duration and activity, previous disease course including response and side-effects of medication)

  • Check stool culture, C. difficile assay (and parasites if travel history)

Reassess disease

ECCO statement 3G (UC 2017)

Microbial testing is recommended in patients with colitis relapse. This includes testing for C. difficile and Cytomegalovirus infection [EL3]

ECCO statement 11C (UC 2017)

Mild to moderately active left-sided ulcerative colitis should initially be treated with an aminosalicylate enema ≥ 1 g/day [EL1] combined with oral mesalamine ≥ 2.4 g/day [EL1], which is more effective than oral or topical aminosalicylates, or topical steroids alone [EL1]. Topical mesalamine is more effective than topical steroids [EL1]. Once-daily dosing with mesalamine is as effective as divided doses [EL1]

Further information

  • Treat based on disease activity and extent

  • Exclude C. difficile infection, especially in those hospitalised or who have received antibiotics recently

  • Consider flexible sigmoidoscopy and biopsy to assess response and exclude other diagnoses including CMV

  • Add thiopurine if relapse within 3 months of steroid-induced remission

Treatment based on activity / extent

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