ulcerative colitis

Question 1

What is it and what are the characteristics

Answer 1

• chronic inflammatory condition characterised by diffuse mucosal inflammation
• relapsing remitting pattern
• lifelong
• associated with significant morbidity

Question 2

pattern of inflammation

Answer 2

• diffuse mucosal inflammation
• pattern of inflammation is continuous, extending from rectum upwards to a varying degree

Question 3

most commonly presents in

Answer 3

15-25 years
but diagnosis can be made at any age

Question 4

common symptoms of active disease or relapse

Answer 4

• bloody diarrhoea
• abdominal pain
• urgent need to poo

Question 5

complications

Answer 5

• increased risk colorectal cancer
• secondary osteoporosis
• VTE
• toxic megacolon

Question 6

Severity classifications

Answer 6

• mild, moderate or severe using the Truelove and Witt’s Severity Index to assess bowel movements, HR, ESR, pyrexia, melaena (tarry stools due to upper GI bleed) or anaemia

Question 7

Anti-diarrhoeal drugs

Answer 7

• Can sometimes use loperamide or codeine on advice of specialist
• however contraindicated in acute UC as they can increase the risk of toxic megacolon!

Question 8

Duration of CC course is usually

Answer 8

4-8 weeks depending on CC chosen

Question 9

What is proctitis

Answer 9

inflammation of rectum

Question 10

what is proctosigmoiditis

Answer 10

inflammation of rectum and signed colon

Question 11

what is left sided colitis

Answer 11

disease involving the colon distal to the splenic flexure

Question 12

what is extensive colitis

Answer 12

affecting whole colon

Question 13

treatment of acute mild to moderate UC: proctitis

Answer 13

proctitis = inflammation of rectum
- 1st line for initial presentation or inflammatory exacerbation is topical aminosalicylate
- if remission not achieved within 4 weeks, consider adding oral aminosalicylate
- if response inadequate, consider adding topical or oral CC for 4-8 weeks
- monotherapy with oral aminosalicylate can be considered for pt who prefer not to use enemas or suppositories, but this may not be as effective
- if remission not achieved within 4 weeks, consider + topical or oral CC for 4-8 weeks
- if aminosalicylate unsuitable, topical or oral CC for 4-8 weeks

Question 14

treatment of acute mild to moderate UC: proctosigmviditis and left sided UC

Answer 14

-proctosigmoiditis: inflammation of rectum and sigmoid colon
- 1st line for initial presentation or inflammatory exacerbation: topical aminosalicylate
- if remission not achieved within 4 weeks, consider adding high dose oral aminosalicylate or switching to high dose oral aminosalicylate and 4-8 weeks topical CC
- if response remains inadequate, stop topical treatment and offer oral AS + 4-8 weeks of oral CC
- consider mono therapy with high dose oral AS in pt who prefer not to use enemas or suppositories, but this may not be as effective
- if no remission within 4 weeks, add oral CC for 4-8 weeks
- if AS unsuitable, consider topical or oral CC for 4-8 weeks

Question 15

treatment of acute mild to moderate UC: extensive UC

Answer 15

• 1st line for mild to moderate initial presentation or inflammatory exacerbation: topical + high dose oral AS
• if no remission within 4 weeks, stop topical and offer high dose oral AS + 4-8 weeks oral CC
• if AS unsuitable, consider oral CC 4-8 weeks

Question 16

treatment of acute moderate to severe UC

Answer 16

• specialist care, the following can be used
• janus kinase inhibitors
• sphingosine-1-phosphate receptor modulators
• biological drugs (e.g. anti-lymphocyte mabs, interleukin inhibitors, TNF-a inhibitors)

Question 17

treatment of acute severe UC

Answer 17

• can be life threatening - medical emergency
• immediate hospital admission
• give IV CCs to induce remission whilst assessing need for surgery
• if IV CCs contraindicated, declines or not tolerated, consider surgery or IV Cs (unlicensed)
• 2nd line for pt who have little/no improvement within 72h IV CCs or symptoms worsen, combination of IV Cs + IV CCs or surgery
• if Cs contraindicated or inappropriate, infliximab can be used
• in pt who experience initial response to steroids followed by deterioration, take tool cultures to exclude presence of pathogens
• consider cytomegalovirus activation

Question 18

maintaining remission in mild, moderate or severe UC

Answer 18

• maintenance therapy with AS recommended in most pt
• CCs not suitable due to their SE

Question 19

maintaining remission in mild, moderate or severe UC - after mild to moderate inflammatory exacerbation of proctitis or proctosigmoiditis

Answer 19

• rectal AS started alone or in combo with oral AS
• administered daily as part of intermittent regimen, e.e. 2-3x weekly or the first 7 days of each month
• oral AS alone in pt who prefer not to sue enemas or suppositories, although this may not be as effective

Question 20

maintaining remission in mild, moderate or severe UC - after mild to moderate inflammatory exacerbation of left sided or extensive UC

Answer 20

low dose oral AS

Question 21

single daily doses vs multiple daily dosing

Answer 21

When used to maintain remission, single daily doses of oral aminosalicylates can be more effective than multiple daily dosing, but may result in more SE

Question 22

when can oral azathioprine, mercaptopurine (unlicensed) or MTX be used to maintain remission

Answer 22

IF
- there has been 2 or more inflammatory exacerbations in a 12 month period that required treatment with systemic CCs
- If remission is not maintained by aminosalicylates
- Or following a single acute severe episode
- No evidence to support use of MTX to induce or maintain remission in UC, though its use is common in clinical practice

Question 23

specialist treatments for remission

Answer 23

• BIOLOGICAL DRUGS, JANUS KINASE INHIBITORS, AND SPHINGOSINE-1-PHOSPHATE RECEPTOR MODULATORS FOR MAINTAINING REMISSION OF UC
• Treatment with these agents may be continued into the maintenance phase

Question 24

non drug treatment

Answer 24

• Surgery may be necessary as emergency treatment for severe UC that does not respond to drug treatment
• Pt can also choose to have elective surgery for unresponsive or freq relapsing disease that is affecting their QoL