Ulcerative colitis / Inflammatory bowel disease

Prescribing Notes:

• Specialist advice should be sought if diagnosis is unclear.
• Local therapies using topical treatment will resolve symptoms in most patients who have bloody diarrhoea from ulcerative proctitis, without side effects. 
• Acute mild to moderate disease affecting the rectum (proctitis) is treated initially with local application of aminosalicylate. Alternatively, if this is not tolerated or not effective, a local corticosteroid can be considered.
• Some systemic absorption of steroid occurs from rectal steroids; prolonged use may lead to adrenal suppression and steroid side effects and should be avoided.
• A combination of a local and an oral aminosalicylate can be used in proctitis if topical treatment fails to adequately control symptoms.
• If the patient presents with severe disease (6 or more bloody stools a day and systemic symptoms) urgent admission should be considered and discussion with secondary care is recommended.
• 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. Maintenance rectal therapy does not need to be given every day and twice weekly treatments will be sufficient for some patients.

Prescribing Notes:

• Specialist advice should be sought if diagnosis is unclear.
• Local therapies using topical treatment will resolve symptoms in most patients who have bloody diarrhoea from rectosigmoid disease, without side effects. 
• Acute mild to moderate disease affecting the rectosigmoid is treated initially with local application of aminosalicylate. Alternatively, if this is not tolerated or not effective, a local corticosteroid can be considered.
• Some systemic absorption of steroid occurs from rectal steroids; prolonged use may lead to adrenal suppression and steroid side effects and should be avoided.
• A combination of a local and an oral aminosalicylate can be used in distal colitis if topical treatment fails to adequately control symptoms.
• If the patient presents with severe disease (6 or more bloody stools a day and systemic symptoms) urgent admission should be considered and discussion with secondary care is recommended.
• 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. Maintenance rectal therapy does not need to be given every day and twice weekly treatments will be sufficient for some patients.

Prescribing Notes:

• Specialist advice should be sought if diagnosis is unclear.
• A combination of a local and an oral aminosalicylate can be used in disease above the rectosigmoid if topical treatment fails to adequately control symptoms.
• If the patient presents with severe disease (6 or more bloody stools a day and systemic symptoms) urgent admission should be considered and discussion with secondary care is recommended.

Prescribing Notes:

• Specialist advice should be sought if diagnosis is unclear.
• Severe exacerbations of ulcerative colitis require systemic corticosteroids. Patients passing 6 or more bloody stools a day with systemic disturbance should be referred to secondary care urgently.
• If there are two or more inflammatory exacerbations in a 12-month period that require treatment with oral corticosteroids, or if remission cannot be maintained by aminosalicylates, patients should be considered for second line medical therapy.  Azathioprine and mercaptopurine may be used on specialist advice in selected patients with steroid dependent inflammatory bowel disease as a steroid sparing agent. Specialist can advise on other treatment options.

Prescribing Notes:

• If it is necessary to switch a patient to a different brand of mesalazine, the patient should be advised to report any change in symptom.
• Aminosalicylates can cause blood disorders; patients should report any unexplained bleeding, bruising, purpura, sore throat, fever or malaise occurring during therapy. A blood count should be performed and the drug stopped immediately if a blood dyscrasia is suspected.
• Interstitial nephritis is a rare side effect of mesalazine. Renal function should be measured at start of treatment, at three months of treatment and then annually thereafter.
• Patients previously maintained and stable on other aminosalicylates need not be changed to a different brand.
• Patients previously being prescribed Asacol may be switched to Octasa as they are bioequivalent.
• Avoid aminosalicylates (mesalazine, olsalazine, sulfasalazine) in patients allergic to aspirin, and those with renal failure (eGFR < 20ml/minute/1.73m²).
• Mild disease extending beyond the rectum can be treated with an oral aminosalicylate alone; a combination of a local and an oral aminosalicylate can be used in proctitis or distal colitis.
• The brand should be maintained as per instructions from initiating consultant.

Prescribing Notes:

• Biologic and targeted synthetic DMARDs are reserved for specialist use only for patients with ulcerative colitis in line with national guidance and East Region Formulary Decisions i.e. locally approved health technology assessment approvals and restrictions in line with national guidance.
• Refer to local board prescribing guidelines and MHRA guidance on Janus Kinase (JAK) Inhibitors.
• All biological medicines, including biosimilars, should be prescribed by brand name.
• Further information for patients regarding condition and treatments can be found at Crohn's & Colitis UK
• In NHS Fife, refer to IBD: use of Biological Agents and Small molecules in adult patients

Prescribing Notes:

• Specialist advice should be sought for acute exacerbations or if diagnosis is unclear. Children presenting with a possible flare of inflammatory bowel disease should be discussed with GI team.
• Local therapies using topical treatment will resolve symptoms in most patients who have bloody diarrhoea from ulcerative proctitis, without side effects.
• Acute mild to moderate disease affecting the rectum (proctitis) is treated initially with local application of aminosalicylate. Alternatively, if this is not tolerated or not effective, a local corticosteroid can be considered.
• Some systemic absorption of steroid occurs from rectal steroids; prolonged use may lead to adrenal suppression and steroid side effects and should be avoided.
• A combination of a local and an oral aminosalicylate can be used in proctitis if topical treatment fails to adequately control symptoms.
• If the patient presents with severe disease (6 or more bloody stools a day and systemic symptoms) urgent admission should be considered and discussion with secondary care is recommended.
• 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. Maintenance rectal therapy does not need to be given every day and twice weekly treatments will be sufficient for some patients.
• For further information on the treatment of Ulcerative Colitis see NICE guideline NG130 Ulcerative Colitis management.

Prescribing Notes:

• Specialist advice should be sought if diagnosis is unclear. Children presenting with a possible flare of inflammatory bowel disease should be discussed with GI team.
• Local therapies using topical treatment will resolve symptoms in most patients who have bloody diarrhoea from rectosigmoid disease, without side effects.
• Acute mild to moderate disease affecting the rectosigmoid is treated initially with local application of aminosalicylate. Alternatively, if this is not tolerated or not effective, a local corticosteroid can be considered.
• Some systemic absorption of steroid occurs from rectal steroids; prolonged use may lead to adrenal suppression and steroid side effects and should be avoided.
• A combination of a local and an oral aminosalicylate can be used in distal colitis if topical treatment fails to adequately control symptoms.
• If the patient presents with severe disease (6 or more bloody stools a day and systemic symptoms) urgent admission should be considered and discussion with secondary care is recommended.
• 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. Maintenance rectal therapy does not need to be given every day and twice weekly treatments will be sufficient for some patients.

Prescribing Notes:

• Specialist advice should be sought for acute exacerbations and if diagnosis is unclear. Children presenting with a possible flare of inflammatory bowel disease should be discussed with GI team.
• A combination of a local and an oral aminosalicylate can be used in disease above the rectosigmoid if topical treatment fails to adequately control symptoms.
• If the patient presents with severe disease (6 or more bloody stools a day and systemic symptoms) urgent admission should be considered and discussion with secondary care is recommended.
• Acute exacerbation of extensive disease requires systemic corticosteroids.
• Patients receiving prolonged courses of steroids should be given a steroid card.

Prescribing Notes:

• Specialist advice should be sought for acute exacerbations and if diagnosis is unclear. Children presenting with a possible flare of inflammatory bowel disease should be discussed with GI team.
• Severe exacerbations of ulcerative colitis require systemic corticosteroids. Patients passing 6 or more bloody stools a day with systemic disturbance should be referred to secondary care urgently.
• Prednisolone oral solution and soluble tablets are restricted to use in patients who are unable to swallow tablets. These preparations are considerably more expensive than the standard tablets.

Prescribing Notes:

Aminosalicylates

• The aminosalicylate brand should be maintained as per instructions from initiating consultant.
• Different formulations of mesalazine have different release characteristics and should not be regarded as interchangeable; the proprietary name should be specified.
• If it is necessary to switch a patient to a different brand of mesalazine, the patient should be advised to report any change in symptoms.
• Aminosalicylates can cause blood disorders; patients should report any unexplained bleeding, bruising, purpura, sore throat, fever, or malaise occurring during therapy. A blood count should be performed, and the drug stopped immediately if a blood dyscrasia is suspected.
• There are case reports of interstitial nephritis and pneumonitis with mesalazine and sulfasalazine.
• Renal function should be measured at start of treatment, at three months of treatment and then annually thereafter.
• Use with caution in mild to moderate impairment (risk of toxicity including crystalluria); avoid in severe impairment.
• Avoid aminosalicylates (mesalazine, sulfasalazine) in patients allergic to aspirin.
• Disease in the left colon can be treated with an oral aminosalicylate alone, topical treatment (suppository for proctitis) and enema for disease extending beyond rectum into left colon or with a combination of both as directed by the GI specialist plus taking into account patient choice and treatment response.
• Pentasa may cause watery diarrhoea and occasionally headaches. Sulfasalazine produces more side-effects, particularly blood dyscrasias, nausea, headaches and liver dysfunction.

Azathioprine and Mercaptopurine

• Azathioprine and mercaptopurine are used on specialist advice in selected patients with steroid dependent inflammatory bowel disease as a steroid sparing agent. These medicines are appropriate for shared care, refer to local board policies.
• For further information on the treatment of Ulcerative colitis see NICE guideline NG130 Ulcerative colitis: management.
• Bone marrow suppression is generally dose related and reversible. If the patient develops malaise, fever, bruising, bleeding, rash or a sore throat, check the white cell count and discuss with the hospital team.
• Specialist advice should be sought if patients receiving immunosuppressants come into contact with infectious diseases such as chicken pox, if immunity status is unknown.
• Severely immunosuppressed patients should not receive live vaccines. Live vaccines should be postponed until at least 6 months after stopping immunopsuppresive drugs.
• Do not crush or half azathioprine or mercaptopurine tablets.

Prescribing Notes:

• Adalimumab, infliximab, vedolizumab and tofacitinib are approved for Specialist use only in ulcerative colitis. They should only be used in patients who have not responded to conventional therapy or who are intolerant of or have contraindications to conventional therapy. Use is in line with national and local guidelines.
• The brand of adalimumab prescribed depends on health board and choice is dictated at a local level.