Ulcerative Colitis

Question 1

What is ulcerative colitis?

Answer 1

Long-term condition where the colon and rectum become inflamed.

Question 2

Symptoms of ulcerative colitis

Answer 2

Bloody diarrhoea, defecation urgency or abdominal pain

Question 3

Complications of ulcerative colitis

Answer 3

Colorectal cancer
Secondary osteoporosis
Venous thromboembolism
Toxic megacolon

Question 4

What can cause toxic megacolon? Which medication should be avoided?

Answer 4

Infection caused by slowing down of gastric emptying
Loperamide and codeine avoided

Question 5

Difference between Crohn’s and Ulcerative colitis

Answer 5

UC: continuous pattern and affects colon only

Crohn’s: patchy inflammation and affects whole GI tract

Question 6

Types of Ulcerative colitis

Answer 6

Proctitis = inflammation of the rectum
Proctosigmoiditis = inflammation of the rectum and sigmoid colon
Left-sided colitis = inflammation in the colon distal to the splenic flexure
Extensive colitis = affects the colon proximal to the splenic flexure and induces pan-colitis
Pan-colitis = where the whole colon is involved

Question 7

Proctitis

Answer 7

Inflammation of the rectum

Question 8

Proctosigmoiditis

Answer 8

Inflammation of the rectum and sigmoid colon

Question 9

Left-sided colon

Answer 9

Inflammation in the colon distal to the splenic flexure

Question 10

Extensive colitis

Answer 10

Affects the colon proximal to the splenic flexure and induces pan-colitis

Question 11

Pan-colitis

Answer 11

Where the whole colon is involved

Question 12

Considerations for the management of ulcerative colitis

Answer 12

Extent of disease when choosing the route of administration for aminosalicylates and corticosteroids

Question 13

What to offer patient if inflammation is distal?

Answer 13

Rectal preparation e.g., suppositories or enemas

Question 14

What to offer patient if having difficulty retaining liquid enemas?

Answer 14

Foam preparations or suppositories

Question 15

What to offer patient if inflammation is extended?

Answer 15

Systemic medication required

Question 16

Which medication should be avoided in acute ulcerative colitis? Why?

Answer 16

Loperamide and codeine
Can cause toxic megacolon

Question 17

What to offer a patient with proximal faecal loading in proctitis?

Answer 17

Macrogol containing osmotic laxative

Question 18

What is offered to a patient to maintain remission?

Answer 18

Oral aminosalicylates

Single daily doses can be more effective than multiple daily dosing but may result in more side effects

Question 19

First line treatment of acute mild-moderate proctitis

Answer 19

Topical aminosalicylate

Question 20

Treatment of acute mild-moderate proctitis where remission isn’t achieved after 4 weeks of topical aminosalicylate use

Answer 20

Add oral aminosalicylate

Question 21

Treatment of acute mild-moderate proctitis where remission isn’t achieved after 4 weeks of topical aminosalicylate use and inadequate response from oral aminosalicylate use

Answer 21

Topical or oral corticosteroids for 4-8 weeks

Question 22

Treatment of acute mild-moderate proctitis for patients who do not wish to use topical preparations

Answer 22

Can use oral aminosalycilates as first line if preferred however not as effective

Question 23

Treatment of acute mild-moderate proctitis if aminosalicylates are contraindicated

Answer 23

Topical or oral corticosteroid for 4-8 weeks

Question 24

First line treatment of acute mild-moderate proctosigmoiditis

Answer 24

Topical aminosalicylate

Question 25

Treatment of acute mild-moderate proctosigmoiditis where remission isn’t achieved after 4 weeks of topical aminosalicylate use

Answer 25

i) Add high-dose oral aminosalicylate to topical treatment

OR

ii) Switch from topical to high dose oral aminosalicylate + 4-8 weeks of topical corticosteroids

Question 26

Treatment of acute mild-moderate proctosigmoiditis where remission isn’t achieved after 4 weeks of topical aminosalicylate use and inadequate response from oral aminosalicylate use

Answer 26

Stop topical treatment and offer oral aminosalicylate + 4-8 weeks of oral corticosteroids

Question 27

Treatment of acute mild-moderate proctosigmoiditis where remission isn’t achieved after first and second line options

Answer 27

Add oral corticosteroid for 4-8 weeks

Question 28

First line treatment of acute mild-moderate extensive ulcerative colitis

Answer 28

Topical aminosalycilate + high dose oral

Question 29

Treatment of acute mild-moderate extensive ulcerative colitis where remission isn’t achieved after 4 weeks of topical aminosalicylate use

Answer 29

Stop topical aminosalicylate
Offer high-dose oral aminosalicylate + oral corticosteroid for 4-8 weeks

Question 30

When would oral corticosteroids be offered as first line treatment in an acute mild-moderate flare up of ulcerative colitis?

Answer 30

When aminosalicylates are contraindicated

Question 31

Treatment of acute moderate-severe ulcerative colitis flare up

Answer 31

Under specialist care

Janus kinase inhibitors
Sphingosine-1-phsophate receptor modulators
Biological drugs

Question 32

Treatment of acute severe ulcerative colitis

Answer 32

Medical emergency

IV hydrocortisone or methylprednisolone to induce remission and assess for need of surgery

Question 33

Treatment of acute severe ulcerative colitis if IV steroids are contraindicated

Answer 33

Use IV ciclosporin or surgery

Question 34

Treatment of acute severe ulcerative colitis if symptoms haven’t improved within 72 hours of initial treatment

Answer 34

IV steroid + IV ciclosporin

or

Surgery

Question 35

Treatment of acute severe ulcerative colitis if steroids and ciclopsorin are contraindicated

Answer 35

Infliximab

Question 36

Management if the patient initially responds to steroid treatment during an acute severe ulcerative colitis flare up, followed by deterioration

Answer 36

Stool cultures should be taken to exclude the presence of pathogens

Consider cytomegalovirus activation

Question 37

Maintenance treatment of ulcerative colitis

Answer 37

Oral aminosalicylate

Question 38

Which regimen produces a more effective response from aminosalicylates treatment?

Answer 38

Once daily / single daily dosing although may cause more s/e

Question 39

Maintenance treatment of ulcerative colitis following a flare up of mild-moderate proctitis or proctosigmoidtis

Answer 39

Rectal +/- oral aminosalicylates administered daily or as part of an intermittent regimen (twice to three times weekly or first seven days of each month)

Question 40

Maintenance treatment of ulcerative colitis following left-sided or extensive flare up

Answer 40

Low-dose oral aminosalycilate

Question 41

Maintenance treatment if the patient has had 2+ flare ups in 12 months that required treatment with systemic corticosteroids or if remission is not maintained by aminosalicylates or following an acute severe episode

Answer 41

Oral azathioprine or mercaptopurine

Question 42

When would a monoclonal antibody be offered as maintenance therapy of ulcerative colitis

Answer 42

If the patient has had 2+ flare ups in 12 months that required treatment with systemic corticosteroids
If remission is not maintained by aminosalicylates or following an acute severe episode
If oral azathioprine or mercaptopurine have no effect

Question 43

Examples of aminosalicylates

Answer 43

Sulfasalazine, balsalzide, mesalazine, olsalazine

Question 44

Which aminosalicylate requires brand specific prescribing?

Answer 44

Mesalazine

Question 45

Which aminosalycilate can stain bodily fluids? Name the colour

Answer 45

Sulfasalazine
Orange/yellow urine and contact lenses

Question 46

Aminosalicylate monitoring requirements

Answer 46

Nephrotoxic: monitor before, initiation, at 3 months, then annually
Hepatotoxic: monitor at monthly intervals for first 3 months
Blood disorders: monitor at monthly intervals for first 3 months
Perform blood count and stop drug immediately if signs of blood dyscrasia

Question 47

Contraindication of aminosalicylates

Answer 47

Salicylate hypersensitivity