Management of acute ulcerative colitis

Pharmacological management -inducing remission in mild-to-moderate ulcerative colitis

• Proctitis
  • a topical aminosalicylate (U1) is first-line treatment for people with a mild-to-moderate first presentation or inflammatory exacerbation of proctitis
    
    
  • if remission is not achieved within 4 weeks, consider adding an oral aminosalicylate (U2)
    
    
  • if further treatment is needed, consider adding a time-limited course of a topical or oral corticosteroid (U3) (normally 4-8 weeks, depending on the steroid)
    
    
  • for people who decline a topical aminosalicylate:
    • consider an oral aminosalicylate as first-line treatment, and explain that this is not as effective as a topical aminosalicylate
    • if remission is not achieved within 4 weeks, consider adding a time-limited course of a topical or oral corticosteroid (U4)
      
      
  • for people who cannot tolerate aminosalicylates, consider a time-limited course of a topical or oral corticosteroid
    
    
• Proctosigmoiditis and left-sided ulcerative colitis
  • a topical aminosalicylate is first-line treatment for people with a mild-to-moderate first presentation or inflammatory exacerbation of proctosigmoiditis or left-sided UC
    
    
  • if remission is not achieved within 4 weeks, consider:
    • adding a high-dose oral aminosalicylate, OR
    • switching to a high-dose oral aminosalicylate and a time-limited course of a topical corticosteroid
      
      
  • if further treatment is needed, stop topical treatments and offer an oral aminosalicylate and a time-limited course of an oral corticosteroid
    
    
  • for people who decline any topical treatment:
    • consider a high-dose oral aminosalicylate alone, and explain that this is not as effective as a topical aminosalicylate.
    • if remission is not achieved within 4 weeks, offer a time-limited course of an oral corticosteroid in addition to the high-dose aminosalicylate
      
      
  • for people who cannot tolerate aminosalicylates, consider a time-limited course of a topical or an oral corticosteroid
    
    
• Extensive disease
  • a combination of a topical aminosalicylate and a high-dose oral aminosalicylate is first-line treatment for people with a mild-to-moderate first presentation or inflammatory exacerbation of extensive UC
    
    
  • if remission is not achieved within 4 weeks, stop the topical aminosalicylate and offer a high-dose oral aminosalicylate and a time-limited course of an oral corticosteroid
    
    
  • for people who cannot tolerate aminosalicylates, consider a time-limited course of a topical or oral corticosteroid

Inducing remission in moderately to severely active ulcerative colitis

All extents of disease

• infliximab, adalimumab and golimumab (3)
  • recommended, within their marketing authorisations, as options for treating moderately to severely active ulcerative colitis in adults whose disease has responded inadequately to conventional therapy including corticosteroids and mercaptopurine or azathioprine, or who cannot tolerate, or have medical contraindications for, such therapies
    
    
• vedolizumab (4)
  • recommended, within its marketing authorisation, as an option for treating moderately to severely active ulcerative colitis in adults only if the company provides vedolizumab with the discount agreed in the patient access scheme
    
    
• tofacitinib (5)
  • recommended, within its marketing authorisation, as an option for treating moderately to severely active ulcerative colitis in adults when conventional therapy or a biological agent cannot be tolerated or the disease has responded inadequately or lost response to treatment

• filgotinib is a selective inhibitor of the Janus-associated tyrosine kinase JAK1, normally used in rheumatoid arthritis. NICE now recommends using this medication as an option in people who are having a moderate to severe flare of ulcerative colitis. (6) It can only be given in adults and under certain conditions. These are if the more conventional treatments used in a flare:
• Are not tolerated by the patient.
• Are not resulting in an effective disease response.
• Are not resulting in any disease response.

ozanimod (7) is a sphingosine-1-phosphate receptor modulator, which prevents movement of lymphocytes out of lymph nodes, thereby limiting gut inflammation. NICE has recommended ozanimod as an option for treating moderately to severely active ulcerative colitis in adults. It has been shown to be just as effective as conventional treatments. It can only be used if:

• Conventional treatment cannot be tolerated or is not working well enough and infliximab is not suitable; or
• Biological treatment cannot be tolerated or is not working well enough.

• upadacitinib is a selective and reversible inhibitor of the Janus-associated tyrosine kinase JAK1 more commonly used for rheumatoid arthritis. NICE have recommended it as an option for treating moderately to severely active ulcerative colitis in adults. (8) It can only be used if conventional treatments are not tolerated or have stopped working. It is believed to be as effective as other treatments available.

• mirikizumab is a humanised monoclonal antibody that inhibits the release of pro-inflammatory cytokines and has been recommended by NICE as an option for treating moderately to severely active ulcerative colitis in adults when conventional or biological treatment cannot be tolerated, or the condition has not responded well enough or lost response to treatment, but only if: (9)
• a tumour necrosis factor (TNF)-alpha inhibitor has not worked (inadequate response or has lost response to treatment) or
• a TNF-alpha inhibitor cannot be tolerated or is not suitable.

• etrasimod is now recommended by NICE as an option for moderately to severely active ulcerative colitis in people aged 16 years and over when conventional or biological treatments cannot be tolerated or the condition has not responded well enough, or lost response to treatment. (9) Indirect comparisons suggest that it may work better than adalimumab and be as effective as other usual treatments for moderately to severely active ulcerative colitis which has not been previously treated with advanced treatment.

If acute severe ulcerative colitis

All extents of disease

Step 1 therapy

• for people admitted to hospital with acute severe UC (either a first presentation or an inflammatory exacerbation):
  • intravenous corticosteroids should be offered to induce remission AND
  • assess the likelihood that the person will need surgery
    
    
• consider intravenous ciclosporin (U4) or surgery for people:
  • who cannot tolerate or who decline intravenous corticosteroids, OR
  • for whom treatment with intravenous corticosteroids is contraindicated
    
    
• clinicians must take into account the person's preference when choosing treatment

Step 2 therapy

• consider adding intravenous ciclosporin U4 to intravenous corticosteroids or consider surgery for people:
  • who have little or no improvement within 72 hours of starting intravenous corticosteroids, OR,
  • whose symptoms worsen at any time despite corticosteroid treatment
    
    
• take into account the person's preference when choosing treatment.
  • infliximab is recommended as an option for the treatment of acute exacerbations of severely active UC only in patients in whom ciclosporin is contraindicated or clinically inappropriate, based on a careful assessment of the risks and benefits of treatment in the individual patient.
  • in people who do not meet this criterion, infliximab should only be used for the treatment of acute exacerbations of severely active UC in clinical trials

Prescribers are advised to check the Full guideline (1) for detailed guidance.

Notes:

• antidiarrheal agents do not reduce stool frequency in colitis and increase the risk of toxic megacolon (2)
• antibiotics are indicated if doubt exists about the diagnosis (for example, in the case of a first attack) or if the patient has recently travelled to an area where amoebic dysentery is endemic (2)
  • empirical treatment with metronidazole and a quinolone can be started
  • stool should be taken for culture (including assessment of C difficile toxin) in all patients
    
    
• Unlicensed prescribing
  • U1 - some topical aminosalicylates are not licensed for this indication in children and young people.
  • U2 - some oral aminosalicylates are not licensed for this indication in children and young people.
  • U3 - beclometasone dipropionate only has a UK marketing authorisation 'as add-on therapy to 5-ASA containing drugs in patients who are non-responders to 5-ASA therapy in active phase'. Additionally, budesonide (oral or rectal) and prednisolone foam are not licensed in children.
  • U4 - ciclosporin is not licensed for this indication

Reference:

1. NICE. Ulcerative colitis: management. NICE guideline NG130. Published May 2019, reviewed February 2025
2. Feuerstein JD, Isaacs KL, Schneider Y, et al. AGA clinical practice guidelines on the management of moderate to severe ulcerative colitis. Gastroenterology. 2020 Apr;158(5):1450-61.
3. Infliximab, adalimumab and golimumab for treating moderately to severely active ulcerative colitis after the failure of conventional therapy (including a review of TA140 and TA262); NICE Technology Appraisal (Feb 2015).
4. Vedolizumab for treating moderately to severely active ulcerative colitis; NICE Technology Appraisal Guidance, June 2015
5. Banerjee R et al. Tofacitinib use in ulcerative colitis: An expert consensus for day-to-day clinical practice. Indian J Gastroenterol. 2024 Feb;43(1):22-35.
6. Filgotinib for treating moderately to severely active ulcerative colitis. NICE Technology appraisal guidance, June 2022
7. Ozanimod for treating moderately to severely active ulcerative colitis; NICE Technology appraisal guidance, October 2022
8. Upadacitinib for treating moderately to severely active ulcerative colitis; NICE Technology appraisal guidance, January 2023
9. Mirikizumab for treating moderately to severely active ulcerative colitis; Technology appraisal guidance, October 2023
10. Etrasimod for treating moderately to severely active ulcerative colitis in people aged 16 and over; NICE Technology appraisal guidance, March 2024