Salvage therapy for acute severe ulcerative colitis in adults
Prompt medical salvage therapy or colectomy should be considered for patients with acute severe ulcerative colitis who do not respond or continue to deteriorate despite 3 days of intravenous corticosteroid therapy (see Initial therapy for acute severe ulcerative colitis). Lack of response or deterioration can be assessed using the Oxford criteria1) where:
- if assessed on day 3, the patient passes 8 or more stools per day, or 3 or more stools per day with a C-reactive protein (CRP) more than 45 mg/L
- if assessed on day 7, the patient passes 3 or more stools per day with visible blood.
Early specialist consultation is required, and patients should be managed in a specialist centre.
Cytomegalovirus infection should be excluded by sigmoidoscopy and histology.
Medical salvage therapies include intravenous infliximab and ciclosporin. Do not delay therapy as this can lead to poor outcomes. It is reasonable to give one dose of infliximab or ciclosporin while awaiting transfer to a specialist centre or gastroenterologist advice; use:
1infliximab 5 mg/kg by intravenous infusion over 2 hours2 infliximab infliximab infliximab
OR
2ciclosporin 2 mg/kg intravenously, as a 24-hour continuous infusion or given in 2 to 3 divided doses, with each infusion given over at least 2 hours3European Crohn's and Colitis Organisation (ECCO), 2021). ciclosporin ciclosporin ciclosporin
If the above therapy is effective, ongoing treatment with infliximab or ciclosporin is usually required, as guided by the specialist centre or gastroenterologist.
Following salvage therapy, maintenance therapy with a thiopurine should be started for all patients unless contraindicated. Before starting maintenance therapy, follow the recommendations in Considerations before starting immunomodulatory therapy in the Rheumatology guidelines—the considerations are the same as for rheumatological diseases.