Acute Exacerbation Ulcerative Colitis Symptoms

Proctosigmoiditis Causes And Risk Factors

Proctosigmoiditis is a result of chronic inflammation in the colon, like all types of ulcerative colitis. This inflammation is the result of an immune response. Doctors dont know what triggers this immune response.

Some people are more likely than others to develop ulcerative colitis. The risk factors for all types of ulcerative colitis are the same. They include:

• having a family history of ulcerative colitis
• having a history of infection with Salmonella or Campylobacter bacteria
• living at a higher latitude
• living in a developed nation

These factors only increase the risks for ulcerative colitis. Having one or more of these risk factors doesnt mean youll get the condition.

Key Recommendations For Research

1. The effectiveness of immunomodulators in inducing remission in proctitis

In a mild-to-moderate first presentation or inflammatory exacerbation of proctitis that is resistant to standard treatment, what is the effectiveness of topical immunomodulators, such as tacrolimus, in achieving clinical remission and what is the most effective formulation ?

To find out why the committee made the research recommendation on immunomodulators for proctitis see .

2. The effectiveness of immunomodulators in unresponsive ulcerative colitis

What is the effectiveness of oral tacrolimus and systemic methotrexate in the induction of remission in mild-to-moderate ulcerative colitis unresponsive to aminosalicylates?

To find out why the committee made the research recommendation on immunomodulators for unresponsive ulcerative colitis see .

3. The relative effectiveness of corticosteroids for inducing remission in ulcerative colitis

What is the clinical and cost effectiveness of prednisolone, budesonide, and beclometasone in addition to aminosalicylates compared with each other and with aminosalicylate monotherapy for the induction of remission for people with mild-to-moderate ulcerative colitis?

To find out why the committee made the research recommendation on corticosteroids for the induction of remission in mild-to-moderate ulcerative colitis see .

Other Recommendations For Research

Induction of remission for people with moderate ulcerative colitis: prednisolone compared with aminosalicylates

What is the clinical and cost effectiveness of prednisolone compared with aminosalicylates for the induction of remission for people with moderate ulcerative colitis?

Induction of remission for people with moderate ulcerative colitis: prednisolone compared with beclometasone

What is the clinical and cost effectiveness of prednisolone plus an aminosalicylate compared with beclometasone plus an aminosalicylate for induction of remission for people with moderate ulcerative colitis?

Induction of remission for people with subacute ulcerative colitis that is refractory to systemic corticosteroids

What are the benefits, risks and cost effectiveness of methotrexate, ciclosporin, tacrolimus, adalimumab and infliximab compared with each other and with placebo for induction of remission for people with subacute ulcerative colitis that is refractory to systemic corticosteroids?

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Ulcerative Colitis Causes And Risk Factors

Ulcerative colitis happens when your immune system makes a mistake. Normally, it attacks invaders in your body, like the common cold. But when you have UC, your immune system thinks food, good gut bacteria, and the cells that line your colon are the intruders. White blood cells that usually protect you attack the lining of your colon instead. They cause the inflammation and ulcers.

Doctors arenât sure why people get the condition. Your genes may play a role the disease sometimes runs in families. Other things in the world around you may make a difference, too.

Things that can affect your risk of getting ulcerative colitis include:

• Age. Itâs most likely if youâre between 15 and 30 years old or older than 60.
• Ethnicity. The risk is highest in people of Ashkenazi Jewish descent.
• Family history. Your risk could be up to 30% higher if you have a close relative with the condition.

Food and stress donât cause it, but they can trigger a flare of symptoms.

Outcomes And Transition Probabilities

The transition probabilities determined the proportion of patients in each health state over time. Because of the lack of any head-to-head trials between infliximab and cyclosporine, studies with placebo/steroids as a common comparator were selected. Colectomy rates used in the model were based on four studies which included acute severe and moderately severe UC patients admitted in a hospital . The patients in three studies were nonresponsive to IV corticosteroids whereas the patients in the fourth study were not steroid refractory and received steroid therapy as a comparator instead of placebo.

The cumulated relative risk of disease progression on different treatment alternatives was expressed as a relative risk of a surgical procedure. For infliximab the efficacy estimates were derived from studies by Järnerot et al. and Sands et al. whereas for cyclosporine they were derived from DHaens et al. and Lichtiger et al. . The overall combined risks were determined by an indirect comparison of available clinical trials . The analysis dataset and the synthesized cumulative probabilities of colectomy at 3 and 12 months are presented in Tables 1 and 2 for Reference .

Table 1 Cumulative number of colectomies

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Acute Exacerbation Of Ulcerative Colitis

Rectal Treatment for distal ulcerative colitis only

Oral Treatment

Drug Treatment After 57 Days

• Change IV hydrocortisone to: prednisolone oral 40mg each day. Reduce no faster than by 5mg every 57 days. Normally there is gradual reduction over a 48 week period if CRP and stool frequency falling.
• If ulcerative colitis add mesalazine oral :
• Salofalk® MR granules 1.5-3g once daily or in three divided doses .

Alternatives are:

• Pentasa® MR tablets / sachets 24g once dailyor

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Patient Information And Support

1.1.1.

Discuss the disease and associated symptoms, treatment options and monitoring:

• with the person with ulcerative colitis and their family members or carers and
• within the multidisciplinary team at every opportunity.

Apply the principles in the NICE guideline on patient experience in adult NHS services.

1.1.2.

Discuss the possible nature, frequency and severity of side effects of drug treatment for ulcerative colitis with the person, and their family members or carers . Refer to the NICE guideline on medicines adherence.

1.1.3.

Give the person, and their family members or carers information about their risk of developing colorectal cancer and about colonoscopic surveillance, in line with the NICE guidelines on:

Diet Tips During A Flare

A modified diet may help you manage and reduce your UC symptoms. Depending on the person, specific foods may trigger flare-ups or worsen symptoms. As a result, its important to identify and limit these foods.

Your doctor and a dietitian can work with you to find a diet that best manages your symptoms while providing the nutrition you need.

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Finding More Information And Resources

You can see everything NICE says on ulcerative colitis in our interactive flowchart on ulcerative colitis.

To find out what NICE has said on topics related to this guideline, see our web page on inflammatory bowel disease.

For full details of the evidence and the guideline committeeâs discussions, see the evidence reviews. You can also find information about how the guideline was developed, including details of the committee.

NICE has produced tools and resources to help you put this guideline into practice. For general help and advice on putting NICE guidelines into practice see practical steps to improving the quality of care and services using NICE guidance.

Ulcerative Colitis Vs Crohns Disease Vs Irritable Bowel

Other gut diseases can have some of the same symptoms.

• Ulcerative colitis affects only your large intestine and its lining.
• Crohnâs disease causes inflammation, but it affects other places in your digestive tract.
• Irritable bowel syndrome has some of the same symptoms as UC, but it doesnât cause inflammation or ulcers. Instead, itâs a problem with the muscles in your intestines.

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Maintaining Remission In People With Ulcerative Colitis

Proctitis and proctosigmoiditis

1.4.1.

To maintain remission after a inflammatory exacerbation of proctitis or proctosigmoiditis, consider the following options, taking into account the personâs preferences:

• a topical aminosalicylate alone or
• an oral aminosalicylate plus a topical aminosalicylate or
• an oral aminosalicylate alone, explaining that this may not be as effective as combined treatment or an intermittent topical aminosalicylate alone.

Left-sided and extensive ulcerative colitis

1.4.2.

To maintain remission in adults after a mild-to-moderate inflammatory exacerbation of left-sided or extensive ulcerative colitis:

• offer a low maintenance dose of an oral aminosalicylate
• when deciding which oral aminosalicylate to use, take into account the personâs preferences, side effects and cost.

1.4.3.

To maintain remission in children and young people after a mild-to-moderate inflammatory exacerbation of left-sided or extensive ulcerative colitis:

• offer an oral aminosalicylate,
• when deciding which oral aminosalicylate to use, take into account the personâs preferences , side effects and cost.

All extents of disease

Dosing regimen for oral aminosalicylates

1.4.6.

Consider a once-daily dosing regimen for oral aminosalicylates when used for maintaining remission. Take into account the personâs preferences, and explain that once-daily dosing can be more effective, but may result in more side effects.

Moderate Or Extensive Disease

Patients with inflammation proximal to the sigmoid colon or left-sided disease unresponsive to topical agents should receive an oral 5-ASA 5-Aminosalicylic Acid Several classes of drugs are helpful for inflammatory bowel disease . Details of their selection and use are discussed under each disorder . Details of their selection and use are discussed under each disorder . Details of their selection and use are discussed under each disorder or corticosteroid therapy as well as those who are corticosteroid-dependent. Moreover, a combination of immunomodulator and anti-TNF therapy Anti-TNF drugs Several classes of drugs are helpful for inflammatory bowel disease . Details of their selection and use are discussed under each disorder (see Crohn disease treatment and ulcerative colitis… read more is sometimes helpful. Finally, in some patients who fail to respond to corticosteroids, immunosuppressants, or biologics, a trial of the Janus kinase inhibitor tofacitinib, or a trial of sphingosine 1-phosphate receptor modulator ozanimod can be considered.

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General Management And Treatment Options

• Avoid anti-diarrhoeal agents
• Give IV fluids
• Give hydrocortisone sodium succinate IV infusion 100mg every 6 hoursor methylprednisolone sodium succinate IV 30mg infusion every 12 hours. Check which drug is used on your site before prescribing.
• Give low residue diet / oral fluids.
• Give high calorie supplements
• If Hb below normal replace deficient haematinics and consult with the gastroenterology team to advise on the need for transfusion or parenteral iron infusion.
• High risk of venous thromboembolism give thromboprophylaxis : enoxaparin SC 40mg once daily or refer to Thromboprophylaxis dose guide in renal impairment.
• Involve gastroenterologist / gastrointestinal surgeon

*Patient with abdominal pain must be seen and assessed before prescribing analgesia.

Information About Treatment Options For People Who Are Considering Surgery

These recommendations apply to anyone with ulcerative colitis considering elective surgery. The principles can also be applied to people requiring emergency surgery.

Information when considering surgery

1.3.1.

For people with ulcerative colitis who are considering surgery, ensure that a specialist gives the person and their family members or carers information about all available treatment options, and discusses this with them. Information should include the benefits and risks of the different treatments and the potential consequences of no treatment.

1.3.2.

Ensure that the person and their family members or carers have sufficient time and opportunities to think about the options and the implications of the different treatments.

1.3.3.

Ensure that a colorectal surgeon gives any person who is considering surgery and their family members or carers specific information about what they can expect in the short and long term after surgery, and discusses this with them.

1.3.4.

Ensure that a specialist gives any person who is considering surgery and their family members or carers information about:

• diet
• sensitive topics such as sexual function
• effects on lifestyle
• the type of surgery, the possibility of needing a stoma and stoma care.

1.3.5.

Ensure that a specialist who is knowledgeable about stomas gives any person who is having surgery and their family members or carers specific information about the siting, care and management of stomas.

Information after surgery

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Limitations Of The Guideline

Studies included in the network meta-analyses that informed the recommendations for induction of remission in people with left-sided or extensive UC compared with placebo were mostly of very low to low quality with the majority of the networks comprising just one study per arm.18,19

Recommendations for step 2 therapy are based on indirect evidence and consensus and this is reflected in the strength of the recommendations. None of the evidence for the induction of remission was in people clearly identified as failing first step therapy and therefore the treatment effect in this situation, as a second step therapy, may be overestimated.

The use of biological agents is evaluated in NICE technology appraisals 7,8 therefore, they are not considered within the clinical guideline .5 As a result, the evidence for treatment options for the same clinical scenario for example acute severe or moderately severe UC unresponsive to corticosteroids may not have been considered together.

There is increasing awareness of the importance of mucosal healing as an endpoint for treatment, but this outcome was not uniformly available in the studies included in the guideline.

Inducing Remission In People With Ulcerative Colitis

Treating mild-to-moderate ulcerative colitis

Proctitis

1.2.1.

To induce remission in people with a first presentation or inflammatory exacerbation of proctitis, offer a topical aminosalicylate as first-line treatment.

1.2.2.

If remission is not achieved within 4 weeks, consider adding an oral aminosalicylate.

1.2.3.

If further treatment is needed, consider adding a of a topical or an oral corticosteroid.

1.2.4.

For people who decline a topical aminosalicylate:

• consider an oral aminosalicylate as first-line treatment, and explain that this is not as effective as a topical aminosalicylate
• if remission is not achieved within 4 weeks, consider adding a time-limited course of a topical or an oral corticosteroid.

1.2.5.

For people who cannot tolerate aminosalicylates, consider a time-limited course of a topical or an oral corticosteroid.

Proctosigmoiditis and left-sided ulcerative colitis

Extensive disease

1.2.11.

To induce remission in people with a mild-to-moderate first presentation or inflammatory exacerbation of extensive ulcerative colitis, offer a topical aminosalicylate and a high-dose oral aminosalicylate as first-line treatment.

1.2.12.

If remission is not achieved within 4 weeks, stop the topical aminosalicylate and offer a high-dose oral aminosalicylate with a time-limited course of an oral corticosteroid.

1.2.13.

For people who cannot tolerate aminosalicylates, consider a time-limited course of an oral corticosteroid.

The multidisciplinary team

Step 1 therapy

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Treatment Comparators And Clinical Practice

According to the Dutch guidelines for pharmacoeconomic research , a drug should be compared with the standard or usual treatment for which effectiveness has been proven. UC patients hospitalized with an acute exacerbation currently receive IV corticosteroids in addition to their existing immunomodulator therapy. A total of 25% of these patients fail IV steroids and require further medical intervention . Following Dutch guidelines, cyclosporine and surgery were chosen as the treatment comparators .

In general, patients with an acute exacerbation of UC will receive 72 h 4060 mg/day IV prednisolone. Patients refractory to the initial treatment are assumed to receive one of the three identified treatment strategies comprising infliximab, cyclosporine or surgical intervention. Responders to medical treatments were assumed to be discharged from the hospital on the 10th day and moved to an outpatient setting. Patients not responding to medical treatments on or before the 10th day were assumed to progress to surgery.

Infliximab treatment included a first infusion of 5 mg/kg of infliximab on day 4, followed by additional 5 mg/kg infusion doses at week 2 and 6 after the first infusion. Patients on infliximab are expected to respond within 7 days of the first infusion. Following discharge from hospital, all infliximab responders received oral azathioprine for the rest of the 3-month period.

Patients undergoing surgical intervention do not receive concomitant medication .