ulcerative colitis Flashcards
What is it and what are the characteristics
- chronic inflammatory condition characterised by diffuse mucosal inflammation
- relapsing remitting pattern
- lifelong
- associated with significant morbidity
pattern of inflammation
- diffuse mucosal inflammation
- pattern of inflammation is continuous, extending from rectum upwards to a varying degree
most commonly presents in
15-25 years
but diagnosis can be made at any age
common symptoms of active disease or relapse
- bloody diarrhoea
- abdominal pain
- urgent need to poo
complications
- increased risk colorectal cancer
- secondary osteoporosis
- VTE
- toxic megacolon
Severity classifications
- 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
Anti-diarrhoeal drugs
- Can sometimes use loperamide or codeine on advice of specialist
- however contraindicated in acute UC as they can increase the risk of toxic megacolon!
Duration of CC course is usually
4-8 weeks depending on CC chosen
What is proctitis
inflammation of rectum
what is proctosigmoiditis
inflammation of rectum and signed colon
what is left sided colitis
disease involving the colon distal to the splenic flexure
what is extensive colitis
affecting whole colon
treatment of acute mild to moderate UC: proctitis
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
treatment of acute mild to moderate UC: proctosigmviditis and left sided UC
-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
treatment of acute mild to moderate UC: extensive UC
- 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
treatment of acute moderate to severe UC
- 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)
treatment of acute severe UC
- 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
maintaining remission in mild, moderate or severe UC
- maintenance therapy with AS recommended in most pt
- CCs not suitable due to their SE
maintaining remission in mild, moderate or severe UC - after mild to moderate inflammatory exacerbation of proctitis or proctosigmoiditis
- 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
maintaining remission in mild, moderate or severe UC - after mild to moderate inflammatory exacerbation of left sided or extensive UC
low dose oral AS
single daily doses vs multiple daily dosing
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
when can oral azathioprine, mercaptopurine (unlicensed) or MTX be used to maintain remission
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
specialist treatments for remission
- 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
non drug treatment
- 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
