If the condition is in remission:
- regular aminosalicylates
- supply of steroid enemas to be used at first indication of relapse
If chronic active colitis:
- may require continuous treatment with daily steroid enemas (or sometimes oral steroids)
- azathioprine used as a steroid-sparing agent - there is no evidence that this drug increases risk of malignancy in patients with inflammatory bowel disease
- surgery may be indicated if symptoms not controlled by maximal medical therapy
NICE suggest (2):
Pharmacological management - maintaining remission
Proctitis and proctosigmoiditis
- to maintain remission after a mild-to-moderate inflammatory exacerbation of proctitis or proctosigmoiditis, consider the following options, taking into account the person's preferences:
- a topical aminosalicylateU1 alone (daily or intermittent), OR
- an oral aminosalicylateU2 plus a topical aminosalicylateU1 (daily or intermittent), OR ,
- an oral aminosalicylateU2 alone, explaining that this may not be as effective as combined treatment or an intermittent topical aminosalicylate alone
Left-sided and extensive UC
- to maintain remission in adults after a mild-to-moderate inflammatory exacerbation of left-sided or extensive UC:
- a low maintenance dose of an oral aminosalicylate should be offered,
- when deciding which oral aminosalicylate to use, take into account the person's preferences, side effects and cost
- to maintain remission in children and young people after a mild-to-moderate inflammatory exacerbation of left-sided or extensive UC:
- an oral aminosalicylate U2, U5 should be offered
- when deciding which oral aminosalicylate to use, take into account the person's preferences (and those of their parents or carers as appropriate), side effects and cost.
All extents of disease
- consider oral azathioprine U6 or oral mercaptopurine U6 to maintain remission:
- after >=2 inflammatory exacerbations in 12 months that require treatment with systemic corticosteroids, OR
- if remission is not maintained by aminosalicylates
- to maintain remission after a single episode of acute severe UC:
- consider oral azathioprineU6 or oral mercaptopurineU6
- consider oral aminosalicylates if azathioprine and/or mercaptopurine are contraindicated or the person cannot tolerate them.
Dosing regimen for oral aminosalicylates
- consider a once-daily dosing regimen for oral aminosalicylates U7 when used for maintaining remission
- take into account the person' preferences, and explain that once-daily dosing can be more effective, but may result in more side effects.
Notes:
- 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
- U5 - dosing requirements for children should be calculated by body weight, as described in the BNF
- U6 - although use is common in UK clinical practice, not all brands of azathioprine and mercaptopurine are licensed for this indication
- U7 - at the time of publication, not all oral aminosalicylates are licensed for once-daily dosing. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information
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