Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 38-year-old man is evaluated in follow-up after a diagnosis of ulcerative colitis. Ten days ago he was started on prednisone, 60 mg/d, but his symptoms have not improved. He has six to nine bloody bowel movements per day and moderate abdominal pain. He has decreased his oral intake because eating exacerbates his pain and diarrhea.

On physical examination, temperature is 37.0 °C (98.6 °F), blood pressure is 110/56 mm Hg, and pulse rate is 96/min. He is pale but in no distress. The abdomen is diffusely tender without distention, guarding, or rebound.

Laboratory studies reveal a hemoglobin level of 9.7 g/dL (97 g/L) and a leukocyte count of 6300/µL (6.3 × 10⁹/L).

Stool culture and Clostridium difficile assay are negative.

Which of the following is the most appropriate treatment?

A. Increase prednisone to 80 mg/d
B. Initiate adalimumab
C. Initiate ciprofloxacin and metronidazole
D. Initiate mesalamine
E. Initiate sulfasalazine

MKSAP Answer and Critique

The correct answer is B. Initiate adalimumab.

The most appropriate treatment is to initiate an anti–tumor necrosis factor (anti-TNF) agent such as adalimumab. This patient has moderate to severe ulcerative colitis that is not responding to 60 mg/d of prednisone. Moderate to severe ulcerative colitis is often treated with oral glucocorticoids such as prednisone, 40 to 60 mg/d. Patients whose disease does not respond to oral glucocorticoids should be hospitalized and given intravenous glucocorticoids or should be treated with an anti-TNF agent. Randomized controlled clinical trials have shown three anti-TNF antibodies (infliximab, adalimumab, and golimumab) to be effective for inducing and maintaining remission in patients such as this with ulcerative colitis. Indications for hospital admission include dehydration, inability to tolerate oral intake, fever, significant abdominal tenderness, and abdominal distention.

A meta-analysis of clinical trials showed that using doses of prednisone above 60 mg/d provides little if any additional efficacy and produces more side effects.

Ciprofloxacin and metronidazole should be used in patients with severe colitis associated with high fever, significant leukocytosis, peritoneal signs, or toxic megacolon. However, antibiotics are not indicated in a patient such as this with colitis without signs of systemic toxicity.

Patients with mild to moderate ulcerative colitis respond well to 5-aminosalicylate agents. Patients with proctitis or left-sided colitis should receive topical therapy with a 5-aminosalicylate or hydrocortisone suppositories or enemas. If patients require repeated courses of glucocorticoids or become glucocorticoid dependent, thiopurines (6-mercaptopurine or azathioprine) or an anti-TNF agent should be initiated (methotrexate has not been shown to be effective in ulcerative colitis). Anti-TNF agents should be used in patients who do not maintain remission with thiopurines or patients whose disease is refractory to glucocorticoids. It is unlikely that 5-aminosalicylates would be beneficial in this patient with more severe disease that is refractory to prednisone.

Key Point

• Patients with moderate to severe ulcerative colitis whose disease does not respond to oral glucocorticoids should be treated with either intravenous glucocorticoids or an anti–tumor necrosis factor agent.

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