Case 8: 38-year-old male requiring oral steroids for treatment of flare
VISIT 1 First visit to the gastroenterologist
38-year-old male who has had ulcerative colitis involving his entire colon for 4 years. The initial treatment was a combination of 5-ASA given both orally and by enemas.
Since the initial flare the patient has continued on 2.4g 5-ASA.
For 2 months the patient has been feeling very unwell and having 6 bloody bowel movements daily (including 2 bowel movements most nights). He is not having any fevers, but has lost 15 lbs over the past 2 months. Occasionally he has had right-sided abdominal pain and slight nausea but no vomiting.
The doctor orders blood and stool tests, and books a flexible sigmoidoscopy
VISIT 2 At the flexible sigmoidoscopy 2 weeks later
The results of the blood tests shows a low hemoglobin and an elevated CRP (a blood test which suggests inflammation).
The flexible sigmoidoscopy shows severe inflammation
The diagnosis: severely active ulcerative colitis
The treatment: prednisone 40mg orally for 2 weeks, followed by a tapering course of 5mg per week.
VISIT 3 Gastroenterology visit 2 weeks later
The patient was instructed that if he got worse during those 2 weeks he needed to call his doctor. He was also told that it could take up to 2 weeks for the prednisone to start working.
The patient is feeling better. Only 25% of his bowel movements have blood in them. The urgency is much better, his stools are formed and his abdominal pain is much better.
The plan stays in place: To reduce the prednisone by 5mg each week. To continue 5-ASA but because of this flare the dose will increase to 4 g daily
3 months later a flexible sigmoidoscopy was booked to look at the bowel to make sure it has healed.
The important feature of this management plan is that the patient understood that it could take up to 2 weeks for the prednisone to start working.
Though the patient was on prednisone for many weeks, the goal was to come off this medication in a reasonable amount of time. The patient knew that if symptoms were to return as he lowered the dose of prednisone, he was to contact his gastroenterologist as this would likely change his management plan.