Therapy

Give steroids

• iv hydrocortisone 200 mg iv three times a day
• prednisolone 30 mg daily by mouth
• prednisone 30 mg daily by mouth

• An less effective alternative is budesonide ^a  
• Use rectal steroids for mild-to-moderate distal ulcerative colitis

Give 5-aminosalicylates (e.g. mesalazine)

• Give patients with distal ulcerative colitis rectal ^a and oral 5-aminosalicylate ^a  

Give antibiotics

• ciprofloxacin in ulcerative colitis ^a  
• metronidazole in perianal and colonic Crohn's disease ^a  

There is no clear benefit from

• ciprofloxacin in Crohn's disease ^d  
• metronidazole in ulcerative colitis ^d  
• vancomycin ^d  
• anti-tuberculous therapy for Crohn's disease ^a  

Consider using nicotine patches for patients with ulcerative colitis who have relapsed on therapy ^a

Avoid using

• anti-diarrhoeal drugs ^a  
• enteral nutrition ^a  

Ask for a surgical opinion if there are any of the following ^d

• toxic megacolon    
• free perforation of the colon
• massive haemorrhage
• sepsis/septic shock
• severe metabolic disturbance/ secondary organ failure
• failure to improve on medical therapy

Withdraw steroids gradually once clinical symptoms and inflammatory markers are improving. ^a  
Do not reduce the dose based on colonoscopic signs alone. ^a  

For active disease that fails to respond to steroids, consider

• antimetabolites ^a  
  • azathioprine
  • methotrexate
  • 6-mercaptopurine

  Adverse effects are common and careful monitoring is required. ^a  

• cyclosporine ^a  
• infliximab ^a  for Crohn's disease