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gi.ulcerative-colitis.core.v1PRODUCTION
gi.ulcerative-colitis.core.v1

Ulcerative Colitis

gastroenterologychronicacuteadult
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm UC scope; distinguish from Crohn colitis, infectious colitis, IBS

Inputs
1
Actions
0
Advance rule
Set
Advance when

IBD pattern recognised, UC type confirmed

Patient inputs (20)

JAKi contraindications in elderly; pediatric considerations

Truelove-Witts: temp >37.8 → severe

Truelove-Witts: HR >90 → severe; toxic megacolon screen

Hemodynamic stability; ASUC severity

Maintenance choice depends on prior 5-ASA/biologic/JAKi/S1P response/failure

Truelove-Witts: Hgb <10.5 → severe; transfusion threshold

Disease activity; Truelove-Witts and Travis Day 3 Oxford criteria

Mucosal inflammation surrogate (excellent for colonic disease)

Truelove-Witts: ESR >30 → severe

Severity / nutritional status

Drug dosing; pre-biologic

C. diff superinfection mandatory exclusion in flares

Diagnostic + Mayo endoscopic subscore + UCEIS

CMV superinfection exclusion in steroid-refractory ASUC

AXR daily in ASUC — transverse colon >5.5cm = toxic megacolon

Methotrexate / JAKi / S1P contraindicated; biologic continuation pathway

PSC-UC — annual chromoendoscopy from PSC dx; high CRC risk

Thiopurine dosing safety

Pre-biologic latent TB

Pre-biologic HBV reactivation risk

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningtoxic megacolon (ACG 2019)
    Transverse colon >5.5 cm on AXR + systemic toxicity in active colitis (ACG 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmassive hemorrhage or perforation (ACG 2019)
    Massive lower GI hemorrhage OR free air on imaging (ACG 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereASUC Truelove-Witts (ACG 2019)
    ≥6 bloody BMs/day + ≥1 systemic toxicity (T>37.8, HR>90, Hgb<10.5, ESR>30, CRP>30) (ACG 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereTravis Day 3 steroid refractory (Travis Gut 1996)
    CRP >45 OR ≥8 stools/day OR 3-8 stools + CRP >45 at day 3 of IV steroid (Travis Gut 1996)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereCMV colitis steroid refractory (ACG 2019)
    Positive CMV PCR/biopsy in steroid-refractory ASUC (ACG 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatePSC-UC overlap (ACG 2019)
    PSC + UC patient (ACG 2019; ECCO 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildpre-biologic or S1P screen (ACG 2019; ECCO 2022)
    Planning anti-TNF, IL-12/23, IL-23, JAKi, or S1P initiation (ACG 2019; ECCO 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

This dossier does not reference any calculators.

Recommended regimen

Ulcerative colitis — Truelove-Witts severity-driven induction + advanced therapy maintenance (ACG 2025 + AGA 2024 living + ECCO)
axis: uc_severity_pathwaystep 1 - Step 1 — Mild UC (Truelove-Witts mild; Mayo 1-3)
Selected step "Step 1 — Mild UC (Truelove-Witts mild; Mayo 1-3)" — Mild symptoms; <4 BMs/day, no systemic toxicity
  • mesalamine_oral
    first line
    5_ASA
    4-4.8 g PO daily (single dose preferred for adherence) • PO • daily
    triggers: mild_left_sided_or_extensive_UC
    ACG 2025 — first-line for mild-moderate UC; high-dose preferred (≥3 g/day)
    rxcui 52582
  • mesalamine_rectal
    first line
    5_ASA_topical
    1 g PR enema or 1 g suppository daily • PR • daily
    triggers: proctitis_E1, left_sided_UC_E2_for_combined_topical_oral
    Topical superior to oral for proctitis; combined topical+oral best for left-sided
    rxcui 52582
  • sulfasalazine
    second line
    5_ASA_old
    500 mg PO QID titrated to 4 g/day • PO • QID
    triggers: UC_with_seronegative_arthropathy
    Useful in UC + arthropathy; folate supplementation
    rxcui 9524

outpatient playbook — drug actions (7)

  1. 1. mesalamine oral + rectal
    Oral 4-4.8 g/day + rectal 1 g daily for left-sided • PO + PR • daily
    trigger: Mild-moderate UC
    ACG 2025 first-line
  2. 2. budesonide MMX or prednisone
    Budesonide MMX 9 mg/day × 8w OR prednisone 40-60 mg/day taper • PO • daily
    trigger: 5-ASA failure
    Induction
  3. 3. anti-TNF / vedolizumab / ustekinumab
    IFX 5 mg/kg IV induction; vedo 300 mg IV induction; uste weight-based • IV/SC • per agent
    trigger: Steroid-dependent or refractory or biologic-naive moderate-severe
    ACT/GEMINI/UNIFI
  4. 4. tofacitinib / upadacitinib JAKi
    Tof 10 mg BID × 8w → 5 mg BID; upa 45 mg → 30/15 mg daily • PO • BID/daily
    trigger: Moderate-severe; rapid response needed
    OCTAVE/U-ACHIEVE
  5. 5. ozanimod / etrasimod S1P
    Ozan 0.23→0.46→0.92 mg titration; etra 2 mg • PO • daily
    trigger: Moderate-severe; oral preference
    TRUE NORTH/ELEVATE
  6. 6. mirikizumab / risankizumab IL-23i
    Mir 300 mg IV q4w × 12w → 200 mg SC q4w; ris 1200 mg IV induction → 180-360 mg SC q8w • IV → SC • per agent
    trigger: Moderate-severe; class switch
    LUCENT/INSPIRE
  7. 7. maintenance
    Mesalamine maintenance / biologic continuation / immunomodulator • per agent • per agent
    trigger: Sustained remission goal
    Personalised

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Bloody diarrhea ± urgency / tenesmus; Chronic rectal bleeding / mucous in stool; Severe flare with systemic toxicity (Truelove-Witts).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Ulcerative Colitis** (gi.ulcerative-colitis.core.v1).
Phenotype framing: Distinguish UC from Crohn colitis, infectious colitis (C. diff), CMV colitis, ischemic, microscopic, NSAID-induced, radiation, diverticular, CRC, IBS, celiac, Behçet
Scope: Confirm UC scope; distinguish from Crohn colitis, infectious colitis, IBS

No severity triggers fired against current inputs.

Plan

Regimen axis: **Ulcerative colitis — Truelove-Witts severity-driven induction + advanced therapy maintenance (ACG 2025 + AGA 2024 living + ECCO)** — step "Step 1 — Mild UC (Truelove-Witts mild; Mayo 1-3)".
1. mesalamine_oral 4-4.8 g PO daily (single dose preferred for adherence) PO daily (5_ASA, first line) — ACG 2025 — first-line for mild-moderate UC; high-dose preferred (≥3 g/day)
2. mesalamine_rectal 1 g PR enema or 1 g suppository daily PR daily (5_ASA_topical, first line) — Topical superior to oral for proctitis; combined topical+oral best for left-sided
3. sulfasalazine 500 mg PO QID titrated to 4 g/day PO QID (5_ASA_old, second line) — Useful in UC + arthropathy; folate supplementation

Setting playbook (outpatient) — Confirm extent (Montreal E1-E3) + severity (Mayo, Truelove-Witts), induce remission with stepwise therapy (5-ASA → steroid/budesonide-MMX → biologic/JAKi/S1P), maintain remission, surveillance, vaccinations, preconception
4. mesalamine oral + rectal Oral 4-4.8 g/day + rectal 1 g daily for left-sided PO + PR daily — Mild-moderate UC (ACG 2025 first-line)
5. budesonide MMX or prednisone Budesonide MMX 9 mg/day × 8w OR prednisone 40-60 mg/day taper PO daily — 5-ASA failure (Induction)
6. anti-TNF / vedolizumab / ustekinumab IFX 5 mg/kg IV induction; vedo 300 mg IV induction; uste weight-based IV/SC per agent — Steroid-dependent or refractory or biologic-naive moderate-severe (ACT/GEMINI/UNIFI)
7. tofacitinib / upadacitinib JAKi Tof 10 mg BID × 8w → 5 mg BID; upa 45 mg → 30/15 mg daily PO BID/daily — Moderate-severe; rapid response needed (OCTAVE/U-ACHIEVE)
8. ozanimod / etrasimod S1P Ozan 0.23→0.46→0.92 mg titration; etra 2 mg PO daily — Moderate-severe; oral preference (TRUE NORTH/ELEVATE)
9. mirikizumab / risankizumab IL-23i Mir 300 mg IV q4w × 12w → 200 mg SC q4w; ris 1200 mg IV induction → 180-360 mg SC q8w IV → SC per agent — Moderate-severe; class switch (LUCENT/INSPIRE)
10. maintenance Mesalamine maintenance / biologic continuation / immunomodulator per agent per agent — Sustained remission goal (Personalised)

Non-pharmacologic actions:
- CRC surveillance colonoscopy q1-3y per extent and duration
- DEXA if chronic steroid
- Vaccinations (no live on biologic)
- PSC screen (LFTs q6-12mo)
- Preconception counselling + biologic continuation per PIANO
- Smoking cessation note: cessation can flare UC paradoxically — counsel and monitor

AVOID / contraindication checks:
- NSAID avoid in active UC (ACG 2019)
- Antibiotics no role in uncomplicated UC (ACG 2019)
- JAKi caution age >50 with CV RF per FDA (AGA 2020)
- S1P check ECG + ophthalmology pre Rx (ECCO 2022)
- Thiopurine check TPMT/NUDT15 (ACG 2019; ECCO 2022)
- CMV rule out in steroid refractory (ACG 2019)
- Cyclosporine target trough 300 400 ng/mL (ACG 2019)
- Opioid/anti diarrheal avoid in ASUC — toxic megacolon risk (ACG 2019; NICE 2019)

Monitoring

Regimen monitoring:
- fecal calprotectin q3-6mo (ACG 2019; STRIDE-II Turner 2021)
- CRP q3-6mo (ACG 2019)
- hemoglobin in active disease (ACG 2019)
- CBC/LFT/BMP on immunomodulator (ACG 2019)
- thiopurine metabolites (ACG 2019; ECCO 2022)
- biologic trough and ADA (AGA 2020)
- lipid panel q3mo on JAKi (AGA 2020)
- ECG pre-S1P and pulse check first month (ECCO 2022)
- ophthalmology pre-S1P and q4-6mo (ECCO 2022)
- CRC surveillance colonoscopy q1-3y per extent and duration (ACG 2019; NICE 2019)
- DEXA if chronic steroid (ACG 2019)
- PSC screen LFT q6-12mo (ACG 2019; ECCO 2022)

Setting (outpatient) monitoring:
- Calprotectin + CRP q3-6 mo (ACG 2019; STRIDE-II Turner 2021)
- CBC/LFT/BMP q3 mo on immunomodulator (ACG 2019)
- Biologic trough + ADA (AGA 2020)
- Lipid panel q3mo on JAKi (AGA 2020)
- ECG + pulse on S1P (ECCO 2022)
- Ophthalmology on S1P (ECCO 2022)

Follow-up plan: Post-induction 8-12w; maintenance q3-6mo stable; flare urgent <1w; ASUC daily inpatient; post-colectomy surgical follow-up; CRC surveillance; preconception counselling
- Close-out criterion: follow-up scheduled

Monitoring phase: Calprotectin + CRP q3-6mo, CBC/LFT q3mo on immunomodulator, thiopurine metabolites, biologic trough + ADA, lipid panel on JAKi, ECG pre-S1P, CRC surveillance colonoscopy q1-3yr per duration/extent, bone density on chronic steroids

Disposition

Current setting: outpatient — Confirm extent (Montreal E1-E3) + severity (Mayo, Truelove-Witts), induce remission with stepwise therapy (5-ASA → steroid/budesonide-MMX → biologic/JAKi/S1P), maintain remission, surveillance, vaccinations, preconception

Disposition criteria:
- Continue maintenance if remission (ACG 2019)
- Step up if active despite induction (ACG 2019)
- Switch class if loss of response with adequate trough + ADA (AGA 2020)

Escalation triggers (move to higher acuity):
- ASUC features → ED / inpatient (ACG 2019)
- Toxic megacolon → emergent surgery (ACG 2019; ECCO 2022)
- Massive hemorrhage → IR / surgery (ACG 2019)

Patient Action Plan

**Ulcerative colitis flare action plan**
Personalised values: baseline_calprotectin_CRP, maintenance_therapy, extent_E1_E2_E3, prior_steroid_response.

**In remission — continue maintenance** (green):
Triggers:
- Stable bowel pattern (≤3 BMs/day, formed, no blood)
- No urgency, tenesmus
- Normal energy
- Calprotectin <250 (if measured)
Actions:
- Take maintenance therapy as prescribed (5-ASA, biologic, immunomodulator)
- No NSAIDs
- Keep IBD clinic appointments
- CRC surveillance per plan
- Annual labs

**Caution — early flare, contact IBD team within 24-48 hours** (yellow):
Triggers:
- Increased BMs (>4-5/day)
- New blood in stool
- New urgency or tenesmus
- Mild fatigue or anorexia
- Mild low-grade fever
Actions:
- Continue maintenance therapy + add topical 5-ASA (1 g PR daily) if proctitis-prone
- Hydrate
- Stool sample for C. diff if available
- Contact IBD team within 24-48 hours
Contact provider when:
- Symptoms worsening despite home measures
- Significant blood in stool
- New fever
- Weight loss

**Medical alert — go to ED now** (red):
Triggers:
- ≥6 bloody BMs/day with systemic symptoms (fever >37.8, HR >90, fatigue)
- Severe abdominal pain or distension
- Vomiting, rigid abdomen (perforation)
- Massive hemorrhage
- Severe lightheadedness
- Confusion
Actions:
- Call 911 / go to nearest ED immediately
- Bring updated medication list
- Notify IBD team
Contact provider when:
- Any red zone symptom — ED now, do not wait

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Transverse colon >5.5 cm on AXR + systemic toxicity in active colitis (ACG 2019)
- [LIFE_THREATENING] Massive lower GI hemorrhage OR free air on imaging (ACG 2019)
- [SEVERE] ≥6 bloody BMs/day + ≥1 systemic toxicity (T>37.8, HR>90, Hgb<10.5, ESR>30, CRP>30) (ACG 2019)

Citations

- 2025 ACG UC Guideline (Rubin) + AGA 2024 Living Guideline (updated 2025) + ECCO 2022 Therapeutics + 2024 EIM update + NICE NG130 (2025-2026) + LUCENT (mirikizumab) + TRUE NORTH (ozanimod) + ELEVATE UC 52/12 (etrasimod) + U-ACHIEVE/U-ACCOMPLISH (upadacitinib) + UNIFI (ustekinumab) + OCTAVE (tofacitinib) + ACT 1/2 (infliximab) + VARSITY [PMID:28158501](https://pubmed.ncbi.nlm.nih.gov/28158501/)
- Cited evidence (PMID 31553834) [PMID:31553834](https://pubmed.ncbi.nlm.nih.gov/31553834/)
- Cited evidence (PMID 34587385) [PMID:34587385](https://pubmed.ncbi.nlm.nih.gov/34587385/)
- Cited evidence (PMID 37379135) [PMID:37379135](https://pubmed.ncbi.nlm.nih.gov/37379135/)

Last reconciled with current guidelines: 2026-05-22.
References
  • 2025 ACG UC Guideline (Rubin) + AGA 2024 Living Guideline (updated 2025) + ECCO 2022 Therapeutics + 2024 EIM update + NICE NG130 (2025-2026) + LUCENT (mirikizumab) + TRUE NORTH (ozanimod) + ELEVATE UC 52/12 (etrasimod) + U-ACHIEVE/U-ACCOMPLISH (upadacitinib) + UNIFI (ustekinumab) + OCTAVE (tofacitinib) + ACT 1/2 (infliximab) + VARSITY — PMID:28158501
  • Cited evidence (PMID 31553834) — PMID:31553834
  • Cited evidence (PMID 34587385) — PMID:34587385
  • Cited evidence (PMID 37379135) — PMID:37379135