When to refer for suspected IBD

• Bloody diarrhoea for more than 1 week, particularly if accompanied by tenesmus, urgency, nocturnal episodes, incontinence and negative stool cultures.
• Diarrhoea or abdominal pain + 1 or more of the following:
  • Weight loss
  • Extraintestinal manifestations
  • Family history of IBD
  • Abnormal investigations: iron/B12 deficiency anaemia or elevated CRP

Recognition of severe colitis

Consider admission directly to Gastroenterology for patients with 6 or more bloody motions/day + 1 or more of the following:

• Pulse greater than 90/min
• Fever greater than 37.8°C
• Hb less than 10.5g/dl
• CRP greater than 45mg/l

Induction of remission

Mild-moderate disease: proctitis

• Initial treatment: mesalazine suppositories 500mg - 1g/day.
• If symptoms persist after 3-4 weeks, add oral mesalazine at a dose of 2 - 4g/day (Pentasa®) or 2.4 - 4.8g/day (Octasa®).
• If patient is not improving on combination aminosalicylate therapy then refer to individual patient management plan, or contact consultant.

Mild-moderate disease: left sided or extensive

• Start treatment with mesalazine foam or retention enema plus oral mesalazine 2g/day (Pentasa®) or 2.4g/day (Octasa®).
• In moderately active disease, oral mesalazine 4g/day (Pentasa®) or 4.8g/day (Octasa®) increases clinical response (but not remission) and reduces time to bleeding cessation.
• A reducing course of oral prednisolone is appropriate if symptoms fail to settle ≤ 4 weeks or deteriorate on treatment.

Severe disease

• Phone gastroenterology SpR or consultant

When treating an acute flare with rectal mesalazine, local specialists note:

• It can take up to 14 days before a response to treatment is seen
• Once symptom free, patients should continue treatment for a minimum of 14 days, then alternate days for 7-14 days, then stop
• Some patients may continue treatment several times each week (e.g. alternate days) as maintenance to prevent breakthrough bleeding (unlicensed frequency)

Maintenance of remission

• Approximately 70% of patients with ulcerative colitis will relapse at 12 months.
• Oral mesalazine 2g/ day (Pentasa®) or 2.4g/day (Octasa®) is the first line treatment for maintaining remission. The European Crohn's and Colitis Organisation (ECCO) guidelines recommend that patients remain on a maintenance dose of oral mesalazine of at least 2g per day.
• Patients on higher doses could trial stepping down high dose oral mesalazine after being stable for 6-8 weeks. De-escalation of doses should be considered on an individual basis. Certain patients may need to remain on higher doses to maintain remission (specialist input should be sought for guidance).
• 1g suppositories on alternate days are an acceptable alternative for proctitis (unlicensed frequency).
• It is recommended that mesalazine is continued long-term since this may reduce the risk of colon cancer.
• Patients who are experiencing symptoms on their current regimen should be reviewed and treatment optimised.

Induction of remission

Ileocaecal

• Mild disease: no treatment or budesonide 9mg daily.
• Moderate disease: budesonide 9mg daily or reducing course of prednisolone.

Colonic

• No treatment or reducing course of prednisolone.
• Sulfasalazine 4g - second line option for mild disease associated with arthropathy.

Upper GI

• Proton pump inhibitor (see 1.3.5 Proton pump inhibitors (PPI)) and prednisolone course if necessary.

Maintenance of remission

• Smoking cessation is an important factor in maintaining remission.
• There is no role for mesalazine in medically induced remission.
• Patients who relapse early, or who have steroid dependent or refractory disease will be treated with azathioprine or mercaptopurine.