Flare management
2019 RCGP, PCSG and BSG-endorsed Flare Management Pathways
Flare pathways for use in patients with established Crohn's Disease or Ulcerative Colitis who have uncomplicated disease and who do not have a personalised care plan, and where access to advice from an IBD advice line is not easily accessible.
2019 RCGP, PCSG and BSG-endorsed Flare Management Pathways
Flare pathways for use in patients with established Crohn's Disease or Ulcerative Colitis who have uncomplicated disease and who do not have a personalised care plan, and where access to advice from an IBD advice line is not easily accessible.
Top tips
1. Confirm a flare is happening using blood inflammatory markers (CRP or ESR) or faecal calprotectin,
but don’t delay starting treatment unless symptoms are mild.
2. Discuss flare management with your IBD team unless they have issued a clear care plan for that patient.
Inform them that a flare has occurred.
3. Refer an acutely ill patient to the on-call medical team
(significant fever, tachycardia, hypotension or anaemia).
4. Use alternatives to oral steroids where possible
oral or rectal mesalazine or rectal steroids are the first-line treatment in UC.
Increase the oral mesalazine dose to 4.8g/day if needed.
5. Use oral steroids in CD, or UC not responding to mesalazines:
start with 40mg/day prednisolone tapering by 5mg/week for 8 weeks = 252 x 5mg tablets in total.
6. Consider budesonide 9mg/day for 8 weeks as an alternative to prednisolone
for mild to moderate ileal or ileo-caecal CD
(ECCO guidance recommends an additional 4 weeks at 6mg/day).
7. Don’t overprescribe – patients can stockpile steroids and use them to self-treat
rather than seek medical attention and have flares documented.
8. Assess response to treatment after 2 weeks or sooner if clinical deterioration occurs.
9. Discuss escalating the IBD therapy with your local IBD team
if a patient requires more than 2 courses of steroids in 12 months,
they can’t reduce the dose below the equivalent of 15mg prednisolone/day
or a relapse occurs within 6 weeks of stopping steroids.
Remember bone protection when using oral steroids
Co-prescribe calcium + D3, and consider a bisphosphonate
if the patient is >65
or has established osteopenia or osteoporosis
but beware the risks of bisphosphonates including gastric irritation and osteonecrosis of the jaw
11. In Crohn’s Disease, enteral nutrition is often the therapy of choice in children
and can be used to induce remission in adults.
1. Confirm a flare is happening using blood inflammatory markers (CRP or ESR) or faecal calprotectin,
but don’t delay starting treatment unless symptoms are mild.
2. Discuss flare management with your IBD team unless they have issued a clear care plan for that patient.
Inform them that a flare has occurred.
3. Refer an acutely ill patient to the on-call medical team
(significant fever, tachycardia, hypotension or anaemia).
4. Use alternatives to oral steroids where possible
oral or rectal mesalazine or rectal steroids are the first-line treatment in UC.
Increase the oral mesalazine dose to 4.8g/day if needed.
5. Use oral steroids in CD, or UC not responding to mesalazines:
start with 40mg/day prednisolone tapering by 5mg/week for 8 weeks = 252 x 5mg tablets in total.
6. Consider budesonide 9mg/day for 8 weeks as an alternative to prednisolone
for mild to moderate ileal or ileo-caecal CD
(ECCO guidance recommends an additional 4 weeks at 6mg/day).
7. Don’t overprescribe – patients can stockpile steroids and use them to self-treat
rather than seek medical attention and have flares documented.
8. Assess response to treatment after 2 weeks or sooner if clinical deterioration occurs.
9. Discuss escalating the IBD therapy with your local IBD team
if a patient requires more than 2 courses of steroids in 12 months,
they can’t reduce the dose below the equivalent of 15mg prednisolone/day
or a relapse occurs within 6 weeks of stopping steroids.
Remember bone protection when using oral steroids
Co-prescribe calcium + D3, and consider a bisphosphonate
if the patient is >65
or has established osteopenia or osteoporosis
but beware the risks of bisphosphonates including gastric irritation and osteonecrosis of the jaw
11. In Crohn’s Disease, enteral nutrition is often the therapy of choice in children
and can be used to induce remission in adults.
