The patient was fluid resuscitated and initial workup started with a complete blood count, complete metabolic panel, serum inflammatory markers, and stool studies including C. difficile, and bacterial culture. ESR and CRP are elevated. Stool infectious studies were negative. Flexible sigmoidoscopy showed Mayo 3 disease in the descending colon and Mayo 2 disease in the rectosigmoid colon.
What would be your initial therapy for this patient?
PO Prednisone 40mg/day
PO Prednisone would not be expected to act quickly enough to induce remission in this patient with a clinically and endoscopically severe disease flare.
IV Infliximab 5-10mg/kg
IV Infliximab is one of two commonly used rescue therapies for acute severe UC refractory to first line induction therapy. In addition, while steroids are the usual initial step, if negative TB and Hepatitis serologies, infliximab can be used to avoid steroids in the appropriate patient.
IV Cyclosporine 4mg/kg/day
IV Cyclosporine is one of two commonly used rescue therapies for acute severe UC refractory to first line induction therapy but is not used first line.
PO Delated Release Mesalamine 3.8g/day
PO (or rectal) Mesalamine would not be expected to be potent enough or to act quickly enough to induce remission in this patient with a clinically and endoscopically severe disease flare.
IV Methylprednisolone 40-60mg/day
IV steroids are the mainstay in therapy for inducing remission for acute ulcerative colitis. 5-7 days of IV steroids are required prior to determining if a patient has failed this first line therapy.
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