1.5.1.1 Acute Exacerbation of ulcerative colitis

Rectal Treatment – for distal ulcerative colitis only (proctitis/proctosigmoiditis)

ChoiceDrugDosage
Prescribe by brand
1st choice

Mesalazine enema - 1st choice for distal (rectosigmoid) colitis
Available as:
Salofalk® mesalazine rectal foam (14 doses)
or
Pentasa® Mesalazine Enema (1g/100ml)

Doses: Mild ulcerative colitis affecting sigmoid colon and rectum, 2 metered applications (mesalazine 2g) into the rectum at bedtime or in 2 divided doses

 

Pentasa® Mesalazine Enema: One enema (1g/100ml) administered at bedtime

Or

Mesalazine suppositories 1g Available as:
Salofalk® 1g suppositories (cost-effective choice)

or
Pentasa® 1g suppositories 

Dose: Acute mild to moderate ulcerative proctitis, one Salofalk 1g suppository once daily inserted into the rectum

 

Dose: acute attack of proctitis, 1g daily for 2-4 weeks

Oral Treatment

ChoiceDrugDosage
Prescribe by brand
1st choices

Oral mesalazine Available as:
Octasa® M/R tablets 400mg, 800mg, 1600mg

Octasa® M/R tablets 400mg, 800mg: 2.4-4.8g once daily or in divided doses (doses over 2.4g daily in divided doses only); Octasa® M/R tablets 1600mg: 2.4-4.8g once daily or in divided doses (note 1600mg tablets can be given in doses up to 4.8g as a once daily dose)

Or
Pentasa® M/R tablets 500mg, 1g; sachets 1g, 2g, 4gPentasa® M/R tablets: acute treatment, up to 4g daily once daily or in divided doses
Or
Salofalk (mesalazine m/r) granules, 1.5g, 3g sachetsSalofalk m/r granules: 1.5-3g once daily, dose preferably taken in the morning
2nd line
(Add on therapy if insufficient response to 5-ASA monotherapy)
Prednisolone tablets 1mg, 5mgDose: 30-40mg daily (up to 1mg/kg) for 1 week, reducing by 5mg weekly thereafter according to patient response

 

Prescribing Notes

  • Refer to CKS and ECCO for further information on the prescribing of aminosalicylates in ulcerative colitis and Crohn’s disease
  • Drugs used to maintain or induce remission in inflammatory bowel disease should always be started by a specialist, but they may be continued and monitored by a GP in primary care as per shared care arrangements.
  • For acute attacks, prescribers may consider titrating doses according to response whilst awaiting specialist admission.
  • Maintenance rectal therapy is an appropriate treatment strategy for rectal disease. Suppositories are the treatment of choice for patients with inflammation confined to the rectum; enemas should be used for more extensive inflammation.
  • Foam and liquid appear to be equally effective in treating patients with distal ulcerative colitis. Foam enemas are generally preferred because they are easier to administer and retention is more comfortable. However, liquid enemas are more effective for proximal disease as they travel further. Suppositories are usually better tolerated than enemas.
  • Mesalazine enemas are likely to be more effective than steroid enemas. Steroid enemas should be reserved for those patients who do not respond to mesalazine. Please note prednisolone foam enemas are very high cost. Predsol® retention enema 20mg/100ml rectal solution is a cost effective option. If a steroid foam is required, Budenofalk® (budesonide) rectal foam is less expensive than prednisolone foam.
  • There is no evidence to show that any one oral preparation of mesalazine is more effective than another; however, the delivery characteristics of oral mesalazine preparations may vary. If it is necessary to switch a patient to a different brand of mesalazine the patient should be advised to report any changes in symptoms.
  • Patient tolerability can vary between mesalazine products therefore it is worth trying a few different products – see BNF for full range of products.
  • Acute exacerbation of extensive disease requires systemic corticosteroid.