Internal Medicine

0521779407-21 CUNY1086/Karliner 0 521 77940 7 June 7, 2007 18:59

1478 Ulcerative Colitis

➣mild: <4 BMs/day, with or without blood, no systemic toxicity,

CBC and ESR are normal

➣moderate: >4 BMs/day with minimal systemic toxicity

➣severe: >6 BMs/day, fever, tachycardia, anemia, thrombocytosis,

elevated ESR, hypoalbuminemia

■Extent:

➣proctitis, proctosigmoiditis, left-sided colitis, pancolitis

General Management

■Complete baseline evaluation: lab tests, colonoscopy, ?SBFT

specific therapy

Maintenance therapy:

■Mild-moderate colitis

➣oral aminosalicylates:

sulfasalazine 2–4 g/day, mesalamine 4–4.8 g/day or balsalazide

6.75 g/day

effective maintenance drugs within 2–4 weeks in 40 to 80% of

patients

intolerance to sulfapyridine moiety of sulfasalazine is common

(headache, nausea), as are mild allergic reactions (skin rash);

severe allergic reactions (e.g., fibrosing alveolitis, pericarditis,

pancreatitis, agranulocytosis) are rare

abnormal sperm count, motility and morphology occur com-

monly with sulfasalazine (and not mesalamine) but are

reversible with discontinuation of medication

low-grade hemolysis on sulfasalazine is not unusual but is

rarely severe

sulfasalazine may interfere with folic acid absorption

interstitial nephritis from mesalamine is rare but may be irre-

versible

■Moderate-severe colitis:

➣Add azathioprine (Aza) or 6-mercaptopurine (6MP) – start at a

low dose (50 mg/d) and slowly increase the dose by adding not

more than 25 mg each month until 2.5 mg/kg/day for Aza or

1.5 mg/kg/day for 6MP or until leukopenia or elevated LFTs,

whichever occurs first. Check CBC and LFTs every 2 weeks when

starting or increasing the dose and every 3 months when on a

stable dose. If TPMT enzyme activity is checked initially and is

normal, then one can start at a higher dose and increase the dose

at a faster rate to achieve earlier effect.