Ulcerative collitis Flashcards
What is UC?
Mucosal inflammation of the colon- starting in the rectum and extending continuously in the colon.
What are the symptoms of UC?
- Recurring diarrhoea that may contain blood or mucus
- Cramping and stomach pain
- Urgency to defecate
What percentage of patients often need surgery 10 years from diagnosis?
15-20%
What are the types of surgery that UC patients may have?
- Sub-total colectomy : removal of colon
- Procto-colectomy: Entire removal of colon, rectum and anal canal
What are the aims of therapy for UC patients?
- Decrease symptoms
- Increase quality of life
- Induce and maintain remission
- Minimize drug-associated toxicity
What does the Montreal classification classify a patients UC based on?
The extent and severity of the disease
E1= proctitis
E2= Left-sided
E3= Extensive
Severity
S0= Clinical remission = asymptomaic
S1= Mild = 4 or less stools +/- blood, no systemic illness, normal inflammatory markers
S2= Moderate= greater than 4 stools, minimal signs of systemic toxicity
S3= Severe= 6+ stools, pulse = 90+ bpm, increased temp 37.5 degrees + , decrease in haemoglobin, increased ESR
What factors influence the choice of therapy given to UC patients?
- Severity - NICE
- Extent
- Disease location - NICE
- Previous response to therapy
- Presence of complications
- Risk factors- patient charateristics, risks vs benefit, cost
On diagnosis, what percentage of patients have proctitis?
30-60%
On diagnosis, what percentage of patients have left-sided colitis?
16-45%
On diagnosis, what percentage of patients have extensive pancreatitis?
14-35%
What is proctitis?
Inflammation of the lining of the rectum
According to NICE guidelines, what is the recommended induction therapy for mild-moderate UC specifically affecting the rectum (Proctitis)?
1st line: Topical aminosalicylate
- Preferably suppositories as they deliver directly to the rectum (Enemas deliver further up and so pool in the sigmoid)
- If remission is not achieved in 4 weeks, add an oral aminosalicylate
- If this is still insufficient, consider topical or oral corticosteroids- short-term use only!
e.g. oral prednisolone 40mg OD for 6-8 weeks or Prednisolone 5mg suppository OD
What is more effective in mild-moderate proctitis, oral or topical aminosalicyclate?
TOPICAL!
But patients offer decline suppositories
According to NICE guidelines, what is recommended for inducing remission in mild-moderate UC (proctosigmoiditis + left-sided colitis)?
- Topical aminosalicylate- as the condition has moved to the sigmoidal /distal area, an enema is preferred- 1g per day
- If remission has not been achieved within 4 weeks:
- Add a high dose oral salicylate- 2/3g per day
- Or switch to high-dose oral aminosalicylate AND time-limited topical corticosteroid
- If still inefficient- Stop topical treatment and offer oral aminosalicylate and time-limited oral corticosteroid
According to NICE guidelines, what is recommended for inducing remission in mild-moderate extensive colitis?
Topical aminosalicylate and high-dose oral aminosalicylate
- If remission is not achieved in 4 weeks, stop topical treatment and offer time-limited course of corticosteroids
According to NICE guidelines, what is the recommended therapy for inducing remission in moderate-severe UC?
Oral corticosteroid e.g. Prednisolone 40-60mg OD- given as a single daily dose as it has the same effectiveness as dividing the doses but dividing increases the risk of adrenal suppression
- If conventional therapies are inadequate- can use biological agents and Janus kinases e.g. Infliximab, adalimumab, golimumab,
Why are daily doses of steroids not divided into multiple doses?
Because it has the same therapeutic effects
- but dividing the doses increases the risk of adrenal suppression
In what order are the biological agents and janus kinases used in moderate-severe UC, where conventional therapy is inadequate?
Monoclonal antibodies- infliximab, adalimumab, golimumab, are used if conventional therapies are inadequate
- Vedolizumab is used if inadequate response to conventional therapy or TNF antagonists
- Tofacitinib is used when conventional therapies or biologic therpay is inadequate or lost
What treatment is given to induce remission in acute severe cases of uc?
Patients should be hospitalised:
- Give IV corticosteroids e.g. Methylprednisolone 60mg/day or hydrocortisone 100mg QDS
- If steroids don’t show a response within 72 hours- consider adding iv ciclosporin
- if ciclosporin is clinically inappropriate, add infliximab
If steroids are contraindicated/intolerant, consider:
- IV ciclosporin
- Surgery
- Assess the likelihood of needing surgery
also
IV fluids
electrolyte imbalance
stool cultures
vte prophylaxis
nutrients support
What criteria is recommended by NICE to determine whether patients have severe uc?
Patients are assessed against Truelove and Witts criteria:
- 6+ bloody stools per day
And at least one of:
high temp (37.8 +)
Pulse 90 bpm+
Haemoglobin less than 105g/L
CRP 30mg/L +
If IV corticosteroids don’t show a response within 72 hours in severe hospitalised cases, what is the next step?
Consider adding IV Ciclosporin
If Ciclosporin is inappropriate for a patient, what is the add-on therapy to corticosteroids in severe hospitalised UC cases?
Can use Infliximab
What is the recommended treatment for maintaining remission in mild-moderate proctitis/proctosigmoiditis?
Topical aminosalicyclates alone
- either daily
- or intermittently- when noticing flares
- Or oral aminosalicylates and topical aminosalicyclates
- Oral aminosalicylates alone - tell the patient that isn’t as effective as topical or combined
What is the recommended treatment for maintaining remission in mild-moderate left-sided and extensive uc?
Low maintenance dose oral aminosalicyclate
When may the use of mercaptopurine or azathioprine be considered for maintaining remission?
If:
- Had 2+ inflammatory exacerbations in 12 months that have required systemic steroids
OR
- Remission not maintained by aminosalicylates
If remission is not maintained by aminosalicylates, what other drugs may be used?
Mercaptopurine or Azathioprine
What drugs are aminosalicyclates?
Mesalazine
Olsalazine
Sulphasalazine
Balsalazide
