Mildly to Moderately Active Left-Sided Ulcerative Colitis Not Responding to Combined Oral and Rectal 5-ASA Therapy

Clinical Scenario

This protocol covers mildly to moderately active left-sided ulcerative colitis in patients who have not achieved remission with — or are intolerant of — combined oral and rectal 5-aminosalicylate (5-ASA) treatment at appropriate doses.

Previous Treatment & Why It Was Not Enough

The preceding line consisted of combined rectal 5-ASA enema and oral 5-ASA. Its goal was induction of remission — specifically, absence of rectal bleeding, no bowel urgency, normalised stool frequency, and a Mayo endoscopic score of 0 or 1. This protocol is the recommended next step when those targets are not reached.

Next-Step Approach

When combined 5-ASA therapy fails or is not tolerated, the evidence-based recommendation involves oral budesonide MMX — a targeted colonic corticosteroid formulation — for induction of remission. The complete regimen, including dosing and duration, is available in the full structured protocol.

Treatment Goals

Induction of remission: absence of rectal bleeding and a Mayo endoscopic score of 0 or 1.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.14309/ajg.0000000000003463

In patients with mildly to moderately active left-sided UC, we suggest rectal 5-ASA enemas at a dose of at least 1 g/daily combined with oral 5-ASA at a dose of at least 2.0 g/daily compared with oral 5-ASA therapy alone for induction of remission.

In patients with mildly to moderately active left-sided UC, who are intolerant or nonresponsive to oral and rectal 5-ASA at appropriate doses (oral at least 2.0 g daily and rectal at least 1 g daily), we recommend oral budesonide Multi Matrix System (MMX) 9 mg/d for induction of remission.

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