Appropriate management of steroids and discharge planning during and after hospital admission for moderate-severe ulcerative colitis

ABSTRACT Background Limited guidance exists for the post-discharge care of ulcerative colitis (UC) patients hospitalized for moderate-severe flares. Methods RAND methodology was used to establish appropriateness of inpatient and post-discharge steroid dosing, discharge criteria, follow-up, and post-discharge biologic or small molecule initiation. A literature review informed the panels voting, which occurred anonymously during two rounds before and after a moderated virtual session. Results Methylprednisolone 40-60mg IV every 24 hours or hydrocortisone 300mg IV three times daily are appropriate for inpatient management, with methylprednisolone 40mg being appropriate if intolerant of higher doses. It is appropriate to discharge patients once rectal bleeding has resolved (Mayo sub score 0-1) and/or stool frequency has returned to baseline frequency and form (Mayo sub score 0-1). It is appropriate to discharge patients on 40mg of prednisone after observing patients for 24 hours in-hospital to ensure stability prior to discharge. For patients being discharged on steroids without in-hospital biologic or small molecule therapy initiation, it is appropriate to start anti-TNF therapy after discharge for anti-TNF naïve patients. For anti-TNF exposed patients it is appropriate to start vedolizumab or ustekinumab for all patients, and tofacitinib for those with a low risk of adverse events. It is appropriate to follow up patients clinically within 2 weeks, and with lower endoscopy within 4-6 months after discharge. Conclusion We provide guidance on the inpatient and post-discharge management of UC patients hospitalized for moderate-severe flares. STUDY HIGHLIGHTS WHAT IS KNOWN Ulcerative colitis patients hospitalized for disease flares are a high-risk population Guidance on evaluation and initial management during flares is provided, however, limited guidance exists on standardization of steroid management and post-discharge care WHAT IS NEW HERE Through a RAND Appropriateness Panel we provide guidance on the inpatient and post-discharge management of steroids, discharge criteria, post-discharge monitoring and management of biologics or small molecule therapies These recommendations will help to bring uniformity to care for this high-risk population, and optimize outcomes in clinical practice