VISIT 1 First visit to the Gastroenterologist

24-year-old female who has had ulcerative colitis involving his entire colon for 2 years. The initial treatment was oral 5-ASA.

Since the initial flare the patient has continued on 3g 5-ASA.

For 3 months the patient has been feeling very unwell and having 8 bloody bowel movements daily (including 1 bowel movement most nights). She is not having any fevers, but has lost 10 lbs over the past 6 weeks.
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 she got worse during those 2 weeks she needed to call her doctor. She 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 her bowel movements have blood in them. The urgency is much better, her stools are formed and her 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.

VISIT 4 6 weeks later an urgent follow-up visit is scheduled

The patient has been taking 20mg of prednisone for the past week and started to notice blood with stool and the stools becoming looser. Urgency with bowel movements has returned.
Treatment plan: Prednisone dose was increased to 40mg daily for 2 weeks with another tapering course

A special blood test was ordered: TPMT enzyme activity (this test was ordered to see if imuran can be broken down properly. If this blood test is abnormal there is an increased risk of the white blood cell count to decrease severely when taking Imuran.)

VISIT 5 2 weeks later

The patient is feeling better again.

Because her TPMT enzyme activity is normal, she begins Imuran. She realizes it can take 2 months for imuran to start working so she begins the medication when instructed. She wants the imuran to start working as soon as possible to allow her to come off of prednisone.
The important feature of this management plan is that when symptoms returned coming off prednisone, a change of plan occurred.

Recurrent use of prednisone, or continuing on prednisone is not appropriate.

Imuran can take 2 months to start working. Imuran can possibly help treat ulcerative colitis in patients who require more than one cycle of prednisone.