A 37-year-old man with 3 months of bloody diarrhea comes to the physician for follow-up after a colonoscopy showed superficial ulcerations from the rectum to the mid descending colon. The biopsies showed chronic active colitis. He was started on prednisone and is currently taking 20 mg. He has 3 nonbloody bowel movements daily. The patient has no other medical problems. He quit smoking 5 months ago. He does not use alcohol or illicit drugs.
Vital signs are normal. The abdomen is soft and nontender. Bowel sounds are present. There is no hepatomegaly or splenomegaly. Rectal examination is normal with no skin tags or external hemorrhoids, but stool is guaiac positive.
Which of the following is the most appropriate next step in management of this patient?

Question

A 37-year-old man with 3 months of bloody diarrhea comes to the physician for follow-up after a colonoscopy showed superficial ulcerations from the rectum to the mid descending colon.  The biopsies showed chronic active colitis.  He was started on prednisone and is currently taking 20 mg.  He has 3 nonbloody bowel movements daily.  The patient has no other medical problems.  He quit smoking 5 months ago.  He does not use alcohol or illicit drugs.
Vital signs are normal.  The abdomen is soft and nontender.  Bowel sounds are present.  There is no hepatomegaly or splenomegaly.  Rectal examination is normal with no skin tags or external hemorrhoids, but stool is guaiac positive.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient has mild-to-moderate ulcerative colitis (UC) and has improved with corticosteroids. Corticosteroids are safe and effective for initial management of UC, but they should not be used for maintenance therapy due to lack of effectiveness and the risk of significant long-term adverse effects (Choice A). The first-line therapy for mild-to-moderate UC is 5-aminosalicylate drugs such as mesalamine. These medications have very few side effects and are effective in inducing and maintaining UC remission. (Choice B) Patients with mild ulcerative proctitis confined to the rectum who have initial remission on corticosteroids usually do not require maintenance therapy. However, for patients with left-sided colitis or more extensive disease, tapering the steroids off without initiating therapy to maintain remission carries a significant risk of recurrent flare. (Choice C) Other therapies, including azathioprine, 6-mercaptopurine, and anti-tumor necrosis factor agents, are appropriate in the setting of moderate-to-severe disease and in steroid-dependent UC. These drugs, however, have more significant side effects than 5-aminosalicylates and should therefore be avoided in this patient. (Choice E) Use of a probiotic alone has not been shown to be effective in maintaining remission in UC. Educational objective: Corticosteroids are useful for achieving initial remission in ulcerative colitis but should not be used to maintain remission. In mild-to-moderate disease, 5-aminosalycilate drugs are recommended for maintenance therapy. Other therapies, including azathioprine, 6-mercaptopurine, and anti-tumor necrosis factor agents, are appropriate for moderate-to-severe disease and steroid-dependent ulcerative colitis. __________ References: Mesalazine for the treatment of inflammatory bowel disease. (http://www.ncbi.nlm.nih.gov/pubmed/23767798) My treatment approach to the management of ulcerative colitis. (http://www.ncbi.nlm.nih.gov/pubmed/23910410)

A 37-Year-Old Man with 3 Months of Bloody Diarrhea Comes