Ulcerative colitis flare pathway
Exclusions: age under 16, have a stoma or fistula, have had surgery, or on
biological therapy (e.g. Humira).These patients should have access to an IBD
specialist—please contact their team before
making any medication changes.
Ask about triggers. Check adherence to medication. Stop NSAIDs. Consider self-care for mild symptoms including dietary advice and
reducing stress. See rcgp.org.uk/ibd and signpost to crohnsandcolitis.org.uk.
Tests: stool culture, U&E, FBC, ESR/CRP, faecal calprotectin. Stop NSAIDs. Consider self-care for mild symptoms including dietary advice and
reducing stress. Seek advice from the IBD helpline, IBD team or on-call gastroenterologist.
Acute Severe colitis:
6 or more bowel movements plus two or more features of systemic upset:
Visible blood in stool
Pyrexia (temperature greater than 37.8°C)
Pulse rate greater than 90 bpm
Anaemia (Hb <105g/L)
Erythrocyte sedimentation rate >30 mm/hr or CRP >40 mg/L
Maximise oral 5-ASA (mesalazine):
Pentasa 4g, Mezavant XL 4.8g, Octasa 4.8g, Asacol 4.8g, Salofalk 3g
Still symptomatic – consider adding topical therapy:
Mesalazine Salofalk foam enema 2g nocte, Pentasa liquid enema
1g nocte, or Salofalk liquid enema 2g nocte
Or add Clipper 5mg (Beclamethasone) OD for 28 days, or Budesonide
MMX (Cortiment) 9mg OD for 8 weeks.
Visit the NICE website for further information on doses:
Oral prednisolone 40mg od for 7 days then 35mg od for 7 days.
Reducing by 5mg each week over 8 weeks = 252 x 5mg prednisolone
tablets in total.
Remember GI and bone protection. Counsel re: side effects
Inform the IBD team when oral steroids are given. Patients should
not have more than one course of steroids in a year without
considering escalating steroid-sparing agents.
Continue treatment for 8 weeks then revert to maintenance dose
of oral mesalazine
Encourage lifetime compliance
Mesalazine Salofalk suppository 1g nocte, Pentasa 1g suppository nocte
Left sided disease
Mesalazine Salofalk foam enema 1-2g nocte, Pentasa liquid enema 1g
nocte, or Salofalk liquid enema 2g nocte
Budesonide Budenofalk foam enema 2mg nocte, Budesonide Entocort
liquid enema 2g or Prednisolone Predsol liquid enema 20mg nocte
Already taking and still symptomatic – Add oral 5-ASA maximum dose
Discuss with on-call gastroenterologist /medical team May need admission. Discuss with on-call gastro team.May need admission. Discuss with on-call Gastro team.
Improving Seek advice from the IBD team via the IBD hotline
For more information on supporting patients with Crohn’s
or Colitis see the RCGP and Crohn’s & Colitis UK IBD toolkit:
www.rcgp.org.uk/ibd July 2019