Ulcerative Colitis: Management

Key points

• Severity (Truelove & Witts): mild under 4 stools/day with little blood; moderate 4-6/day, no systemic upset; severe over 6 bloody stools/day plus systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers).
• Inducing remission: rectal aminosalicylate/steroid for distal disease (rectal mesalazine superior to rectal steroid), then add oral aminosalicylate, then oral prednisolone second-line.
• Acute severe colitis: admit and give IV corticosteroids first-line. Reassess by day 3 (stool frequency, CRP); if not responding, rescue with IV ciclosporin or infliximab and involve surgeons (consider colectomy). Give VTE prophylaxis.
• Maintaining remission: oral aminosalicylates (mesalazine); azathioprine/mercaptopurine for frequent relapse or steroid dependence.
• Moderate-to-severe or refractory UC → biologics/small molecules: anti-TNF (infliximab, adalimumab, golimumab), vedolizumab, ustekinumab, or a JAK inhibitor (tofacitinib, upadacitinib). Methotrexate is NOT used in UC (unlike Crohn's).

Decision points in this pathway

• Severe colitis (systemic upset)?
• Failing to respond?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.