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

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 naive 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.