Skip to main navigation menu Skip to main content Skip to site footer
##common.pageHeaderLogo.altText##

Review article: Biomedical intelligence

Vol. 141 No. 2526 (2011)

Treatment algorithm for moderate to severe ulcerative colitis

  • M Manz
  • P Michetti
  • F Seibold
  • G Rogler
  • C Beglinger
DOI
https://doi.org/10.4414/smw.2011.13235
Cite this as:
Swiss Med Wkly. 2011;141:w13235
Published
20.06.2011

Summary

The care for a patient with ulcerative colitis (UC) remains challenging despite the fact that morbidity and mortality rates have been considerably reduced during the last 30 years. The traditional management with intravenous corticosteroids was modified by the introduction of ciclosporin and infliximab. In this review, we focus on the treatment of patients with moderate to severe UC. Four typical clinical scenarios are defined and discussed in detail. The treatment recommendations are based on current literature, published guidelines and reviews, and were discussed at a consensus meeting of Swiss experts in the field. Comprehensive treatment algorithms were developed, aimed for daily clinical practice.

References

  1. Silverberg MS, Satsangi J, Ahmad T, Arnott ID, Bernstein CN, Brant SR, et al. Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: Report of a Working Party of the 2005 Montreal World Congress of Gastroenterology. Canadian journal of gastroenterology = Journal canadien de gastroenterologie. 2005;19(Suppl A):5–36.
  2. Kucharzik T, Maaser C, Lugering A, Kagnoff M, Mayer L, Targan S, et al. Recent understanding of IBD pathogenesis: implications for future therapies. Inflamm Bowel Dis. 2006;12(11):1068–83.
  3. Rahimi R, Nikfar S, Abdollahi M. Meta-analysis technique confirms the effectiveness of anti-TNF-alpha in the management of active ulcerative colitis when administered in combination with corticosteroids. Med Sci Monit. 2007;13(7):PI13–8.
  4. Rahimi R, Nikfar S, Larijani B, Abdollahi M. A review on the role of antioxidants in the management of diabetes and its complications. Biomedicine & pharmacotherapy = Biomedecine & pharmacotherapie. 2005;59(7):365–73.
  5. Rezaie A, Khalaj S, Shabihkhani M, Nikfar S, Zamani MJ, Mohammadirad A, et al. Study on the correlations among disease activity index and salivary transforming growth factor-beta 1 and nitric oxide in ulcerative colitis patients. Ann N Y Acad Sci. 2007;1095:305–14.
  6. Jahanshahi G, Motavasel V, Rezaie A, Hashtroudi AA, Daryani NE, Abdollahi M. Alterations in antioxidant power and levels of epidermal growth factor and nitric oxide in saliva of patients with inflammatory bowel diseases. Dig Dis Sci. 2004;49(11-12):1752–7.
  7. Rezaie A, Parker RD, Abdollahi M. Oxidative stress and pathogenesis of inflammatory bowel disease: an epiphenomenon or the cause? Dig Dis Sci. 2007;52(9):2015–21.
  8. Baumgart DC, Sandborn WJ. Inflammatory bowel disease: clinical aspects and established and evolving therapies. Lancet. 2007;369(9573):1641–57.
  9. E.F. Stange SPLT, S. Vermeire, W. Reinisch, K. Geboes, A. Barakauskiene, R. Feakins, et al., for the European Crohn’s and Colitis Organisation (ECCO). European evidence-based Consensus on the diagnosis and management of ulcerative colitis: Definitions and diagnosis. Journal of Crohn’s and Colitis. 2008;2(1):1–23.
  10. D’Haens G, Sandborn WJ, Feagan BG, Geboes K, Hanauer SB, Irvine EJ, et al. A review of activity indices and efficacy end points for clinical trials of medical therapy in adults with ulcerative colitis. Gastroenterology. 2007;132(2):763–86.
  11. Truelove SC, Witts LJ. Cortisone in ulcerative colitis; final report on a therapeutic trial. British medical journal. 1955;2(4947):1041–8.
  12. Farmer RG, Easley KA, Rankin GB. Clinical patterns, natural history, and progression of ulcerative colitis. A long-term follow-up of 1116 patients. Dig Dis Sci. 1993;38(6):1137–46.
  13. Flatmark A, Fretheim B, Gjone E. Early colectomy in severe ulcerative colitis. Scand J Gastroenterol. 1975;10(4):427–31.
  14. Sonnenberg A. Time trends of mortality from Crohn's disease and ulcerative colitis. Int J Epidemiol. 2007;36(4):890–9.
  15. Travis SPL, Lémann M, Øresland T, Bemelman WA, Chowers Y, Colombel JF, et al., for the European Crohn’s and Colitis Organisation (ECCO) European evidence-based Consensus on the management of ulcerative colitis: Current management. Journal of Crohn’s and Colitis. 2008;2(1):24–62.
  16. Ng SC, Kamm MA. Therapeutic strategies for the management of ulcerative colitis. Inflamm Bowel Dis. 2009;15(6):935–50.
  17. Panaccione R, Rutgeerts P, Sandborn WJ, Feagan B, Schreiber S, Ghosh S. Review article: treatment algorithms to maximize remission and minimize corticosteroid dependence in patients with inflammatory bowel disease. Aliment Pharmacol Ther. 2008;28(6):674–88.
  18. Carter MJ, Lobo AJ, Travis SP. Guidelines for the management of inflammatory bowel disease in adults. Gut. 2004;53(Suppl 5):V1–16.
  19. Hoffmann JC, Zeitz M, Bischoff SC, Brambs HJ, Bruch HP, Buhr HJ, et al. Diagnosis and therapy of ulcerative colitis: results of an evidence based consensus conference by the German society of Digestive and Metabolic Diseases and the competence network on inflammatory bowel disease. Z Gastroenterol. 2004;42(9):979–83.
  20. Travis SPL, Stange EF, Lémann M M, Øresland T, Bemelman WA, Chowers Y, et al. European evidence-based Consensus on the management of ulcerative colitis: Current management. Journal of Crohn’s and Colitis. 2008;2(1):24–62.
  21. Marteau P, Probert CS, Lindgren S, Gassul M, Tan TG, Dignass A, et al. Combined oral and enema treatment with Pentasa (mesalazine) is superior to oral therapy alone in patients with extensive mild/moderate active ulcerative colitis: a randomised, double blind, placebo controlled study. Gut. 2005;54(7):960–5.
  22. Sutherland L, Macdonald JK. Oral 5-aminosalicylic acid for induction of remission in ulcerative colitis. Cochrane database of systematic reviews (Online). 2006(2):CD000543.
  23. Lichtenstein GR, Sbreu MT, Cohen R, Tremaine W. American Gastroenterological Association Institute technical review on corticosteroids, immunomodulators, and infliximab in inflammatory bowel disease. Revista de gastroenterologia de Mexico. 2006;71(3):351–401.
  24. Ho GT, Chiam P, Drummond H, Loane J, Arnott ID, Satsangi J. The efficacy of corticosteroid therapy in inflammatory bowel disease: analysis of a 5-year UK inception cohort. Aliment Pharmacol Ther. 2006;24(2):319–30.
  25. Truelove SC, Witts LJ. Cortisone in ulcerative colitis; preliminary report on a therapeutic trial. British medical journal. 1954;2(4884):375–8.
  26. Sutherland L, Macdonald JK. Oral 5-aminosalicylic acid for maintenance of remission in ulcerative colitis. Cochrane database of systematic reviews (Online). 2006(2):CD000544.
  27. Bebb JR, Scott BB. How effective are the usual treatments for ulcerative colitis? Aliment Pharmacol Ther. 2004;20(2):143–9.
  28. Kane SV, Bjorkman DJ. The efficacy of oral 5-ASAs in the treatment of active ulcerative colitis: a systematic review. Rev Gastroenterol Dis. 2003 Fall;3(4):210–8.
  29. Kirk AP, Lennard-Jones JE. Controlled trial of azathioprine in chronic ulcerative colitis. British medical journal (Clinical research ed. 1982;284(6325):1291–2.
  30. Ardizzone S, Maconi G, Russo A, Imbesi V, Colombo E, Bianchi Porro G. Randomised controlled trial of azathioprine and 5-aminosalicylic acid for treatment of steroid dependent ulcerative colitis. Gut. 2006;55(1):47–53.
  31. Stange EF, Travis SPL, Vermeire S, Reinisch W, Geboes K, Barakauskiene A, et al. European evidence-based Consensus on the diagnosis and management of ulcerative colitis: Definitions and diagnosis. 2008 03/01;2(1):1–23.
  32. Dimitroulia E, Spanakis N, Konstantinidou AE, Legakis NJ, Tsakris A. Frequent detection of cytomegalovirus in the intestine of patients with inflammatory bowel disease. Inflamm Bowel Dis. 2006;12(9):879–84.
  33. Matsuoka K, Iwao Y, Mori T, Sakuraba A, Yajima T, Hisamatsu T, et al. Cytomegalovirus is frequently reactivated and disappears without antiviral agents in ulcerative colitis patients. Am J Gastroenterol. 2007;102(2):331–7.
  34. Bruns T, Stallmach A. Drug monitoring in inflammatory bowel disease: helpful or dispensable? Dig Dis. 2009;27(3):394–403.
  35. Teml A, Schaeffeler E, Herrlinger KR, Klotz U, Schwab M. Thiopurine treatment in inflammatory bowel disease: clinical pharmacology and implication of pharmacogenetically guided dosing. Clin Pharmacokinet. 2007;46(3):187–208.
  36. Hindorf U, Lindqvist M, Peterson C, Soderkvist P, Strom M, Hjortswang H, et al. Pharmacogenetics during standardised initiation of thiopurine treatment in inflammatory bowel disease. Gut. 2006;55(10):1423–31.
  37. Rutgeerts P, Sandborn WJ, Feagan BG, Reinisch W, Olson A, Johanns J, et al. Infliximab for induction and maintenance therapy for ulcerative colitis. N Engl J Med. 2005;353(23):2462–76.
  38. Fellermann K, Tanko Z, Herrlinger KR, Witthoeft T, Homann N, Bruening A, et al. Response of refractory colitis to intravenous or oral tacrolimus (FK506). Inflamm Bowel Dis. 2002;8(5):317–24.
  39. Ogata H, Matsui T, Nakamura M, Iida M, Takazoe M, Suzuki Y, et al. A randomised dose finding study of oral tacrolimus (FK506) therapy in refractory ulcerative colitis. Gut. 2006;55(9):1255–62.
  40. Sands BE, Kaplan GG. The role of TNFalpha in ulcerative colitis. J Clin Pharmacol. 2007;47(8):930–41.
  41. Truelove SC, Jewell DP. Intensive intravenous regimen for severe attacks of ulcerative colitis. Lancet. 1974;1(7866):1067–70.
  42. Rosenberg W, Ireland A, Jewell DP. High-dose methylprednisolone in the treatment of active ulcerative colitis. J Clin Gastroenterol. 1990;12(1):40–1.
  43. Turner D, Walsh CM, Steinhart AH, Griffiths AM. Response to corticosteroids in severe ulcerative colitis: a systematic review of the literature and a meta-regression. Clin Gastroenterol Hepatol. 2007;5(1):103–10.
  44. Van Assche G, D’Haens G, Noman M, Vermeire S, Hiele M, Asnong K, et al. Randomized, double-blind comparison of 4 mg/kg versus 2 mg/kg intravenous cyclosporine in severe ulcerative colitis. Gastroenterology. 2003;125(4):1025–31.
  45. Arts J, D’Haens G, Zeegers M, Van Assche G, Hiele M, D’Hoore A, et al. Long-term outcome of treatment with intravenous cyclosporin in patients with severe ulcerative colitis. Inflamm Bowel Dis. 2004;10(2):73–8.
  46. Cohen RD, Stein R, Hanauer SB. Intravenous cyclosporin in ulcerative colitis: a five-year experience. Am J Gastroenterol. 1999;94(6):1587–92.
  47. Epple HJ. Therapy- and non-therapy-dependent infectious complications in inflammatory bowel disease. Dig Dis. 2009;27(4):555–9.
  48. Ferrante M, Vermeire S, Katsanos KH, Noman M, Van Assche G, Schnitzler F, et al. Predictors of early response to infliximab in patients with ulcerative colitis. Inflamm Bowel Dis. 2007;13(2):123–8.
  49. Gisbert JP, Gonzalez-Lama Y, Mate J. Systematic review: Infliximab therapy in ulcerative colitis. Aliment Pharmacol Ther. 2007;25(1):19–37.
  50. Jakobovits SL, Jewell DP, Travis SP. Infliximab for the treatment of ulcerative colitis: outcomes in Oxford from 2000 to 2006. Aliment Pharmacol Ther. 2007;25(9):1055–60.
  51. Jarnerot G, Hertervig E, Friis-Liby I, Blomquist L, Karlen P, Granno C, et al. Infliximab as rescue therapy in severe to moderately severe ulcerative colitis: a randomized, placebo-controlled study. Gastroenterology. 2005;128(7):1805–11.
  52. Kohn A, Daperno M, Armuzzi A, Cappello M, Biancone L, Orlando A, et al. Infliximab in severe ulcerative colitis: short-term results of different infusion regimens and long-term follow-up. Aliment Pharmacol Ther. 2007;26(5):747–56.
  53. Manosa M, Lopez San Roman A, Garcia-Planella E, Bastida G, Hinojosa J, Gonzalez-Lama Y, et al. Infliximab rescue therapy after cyclosporin failure in steroid-refractory ulcerative colitis. Digestion. 2009;80(1):30–5.
  54. Lees CW, Heys D, Ho GT, Noble CL, Shand AG, Mowat C, et al. A retrospective analysis of the efficacy and safety of infliximab as rescue therapy in acute severe ulcerative colitis. Aliment Pharmacol Ther. 2007;26(3):411–9.
  55. Moskovitz DN, Van Assche G, Maenhout B, Arts J, Ferrante M, Vermeire S, et al. Incidence of colectomy during long-term follow-up after cyclosporine-induced remission of severe ulcerative colitis. Clin Gastroenterol Hepatol. 2006;4(6):760–5.
  56. Moss AC, Peppercorn MA. Steroid-refractory severe ulcerative colitis: what are the available treatment options? Drugs. 2008;68(9):1157–67.
  57. Baumgart DC, Macdonald JK, Feagan B. Tacrolimus (FK506) for induction of remission in refractory ulcerative colitis. Cochrane database of systematic reviews (Online). 2008(3):CD007216.
  58. Baumgart DC, Pintoffl JP, Sturm A, Wiedenmann B, Dignass AU. Tacrolimus is safe and effective in patients with severe steroid-refractory or steroid-dependent inflammatory bowel disease – 2a long-term follow-up. Am J Gastroenterol. 2006;101(5):1048–56.