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Management of mild to moderate ulcerative colitis in adults

Author: Richard P MacDermott, MD


Section Editor: Paul Rutgeerts, MD, PhD, FRCP
Deputy Editor: Kristen M Robson, MD, MBA, FACG

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2018. | This topic last updated: May 02, 2018.

INTRODUCTION — Ulcerative colitis (UC) is a chronic inflammatory condition characterized by relapsing and remitting episodes of inflammation limited to the
mucosal layer of the colon. It almost invariably involves the rectum and may extend in a proximal and continuous fashion to involve other portions of the colon.

This topic will review the management of mild to moderate ulcerative colitis. The management of severe ulcerative colitis, steroid-dependent, and steroid-refractory
ulcerative colitis are discussed separately. (See "Management of severe ulcerative colitis in adults" and "Approach to adults with steroid-refractory and steroid-
dependent ulcerative colitis".)

PRETREATMENT EVALUATION — Patients may present with active symptoms of ulcerative colitis as the initial manifestation or as a clinical recurrence of their
disease. The clinical manifestations and diagnosis of ulcerative colitis are discussed separately. (See "Clinical manifestations, diagnosis, and prognosis of ulcerative
colitis in adults".)

When a patient presents with recurrent symptoms, some aspects of the initial evaluation should be repeated in order to exclude alternative or comorbid conditions as
a cause for the symptoms, as well as to assess the current extent and severity of disease. These features are important to guide treatment. In most cases, laboratory
studies and endoscopy are required.

Definitions of disease extent — Different terms are used to describe the extent of involvement of ulcerative colitis [1,2]:

● Ulcerative proctitis refers to disease limited to the rectum

● Ulcerative proctosigmoiditis refers to disease limited to the rectum and sigmoid colon and not involving the descending colon

● Left-sided or distal ulcerative colitis refers to disease that extends beyond the rectum and as far proximally as the splenic flexure

● Extensive colitis refers to disease extending proximal to the splenic flexure but sparing the cecum

● Pancolitis refers to disease extending proximal to the splenic flexure and involving the cecum

Extension of colonic disease may occur over time [3,4]. While clinical symptoms can suggest probable sites of disease activity, colonoscopy is required to determine
the extent of involvement. (See 'Colonoscopy' below.)

Assessment of clinical severity — Patients can present with mild, moderate, or severe disease. Stratification based on clinical severity is important in guiding
management [1]. (See 'Treatment of mildly or moderately active disease' below.)

● Mild – Patients with mild clinical disease have four or fewer stools per day with or without blood, no signs of systemic toxicity, and a normal erythrocyte
sedimentation rate (ESR). Mild crampy pain, tenesmus, and periods of constipation are also common, but severe abdominal pain, profuse bleeding, fever, and
weight loss are not part of the spectrum of mild disease.

● Moderate – Patients with moderate clinical disease have frequent loose, bloody stools (>4 per day), mild anemia not requiring blood transfusions, and abdominal
pain that is not severe. Patients have minimal signs of systemic toxicity, including a low-grade fever. Adequate nutrition is usually maintained and weight loss is
not associated with moderate clinical disease.

● Severe – Patients with a severe clinical presentation typically have frequent loose bloody stools (≥6 per day) with severe cramps and evidence of systemic
toxicity as demonstrated by a fever (temperature ≥37.5°C), tachycardia (HR ≥90 beats/minute), anemia (hemoglobin <10.5 g/dL), or an elevated ESR (≥30
mm/hour). Patients may have rapid weight loss. The management of severe ulcerative colitis is discussed separately. (See "Management of severe ulcerative
colitis in adults".)

Laboratory testing — Blood counts, liver tests, and measurement of C-reactive protein (CRP) and ESR should be performed. CRP and ESR can help determine the
severity of the underlying inflammation [5-7] (see 'Assessment of clinical severity' above). In addition, CRP levels may have a role in distinguishing between patients
with active ulcerative colitis from those with symptoms caused by concomitant functional disorders [7-11]. (See 'Management of persistent symptoms' below.)

In addition, specific serologic testing for sexually transmitted diseases including Neisseria gonorrhea, HSV, and Treponema pallidum should be considered, particularly
in patients with severe rectal symptoms including urgency and tenesmus and with risk factors for these diseases. (See "Clinical manifestations and diagnosis of
Neisseria gonorrhoeae infection in adults and adolescents" and "Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus in HIV-infected
patients" and "Syphilis: Screening and diagnostic testing".)

Stool studies — Stool studies should include stool Clostridium difficile toxin, routine stool cultures (Salmonella, Shigella, Campylobacter, Yersinia), and specific testing
for E. coli O157:H7. Microscopy for ova and parasites (three samples) and a Giardia stool antigen test should also be performed, particularly if the patient has risk
factors such as recent travel. (See "Approach to the adult with acute diarrhea in resource-rich settings", section on 'Etiology' and "Clostridioides (formerly Clostridium)
difficile infection in adults: Clinical manifestations and diagnosis", section on 'Diagnosis'.)

Colonoscopy — Endoscopic evaluation is required to confirm the presence, severity, and extent of inflammation and to exclude the presence of an infection such as
CMV with histology and culture of the tissue obtained on biopsy. Cultures for Neisseria gonorrhea and HSV should be performed in patients with severe rectal
symptoms. Ileocolonoscopy with biopsies in the ileum and the colon is also important in differentiating between ulcerative colitis and Crohn disease. (See "Clinical
manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents" and "Epidemiology, clinical manifestations, and diagnosis of genital
herpes simplex virus in HIV-infected patients" and "Endoscopic diagnosis of inflammatory bowel disease", section on 'Role in differential diagnosis' and "Clinical
manifestations, diagnosis, and prognosis of ulcerative colitis in adults".)

A full colonoscopy should be avoided in hospitalized patients with severe colitis because of the potential to precipitate toxic megacolon. (See 'Assessment of clinical
severity' above.) In such patients, a flexible sigmoidoscopy should be performed and evaluation limited to the rectum and distal sigmoid colon. (See "Endoscopic
diagnosis of inflammatory bowel disease" and "Toxic megacolon".)

TREATMENT OF MILDLY OR MODERATELY ACTIVE DISEASE — Initial treatment of ulcerative colitis is based upon disease severity and extent. (See 'Assessment of
clinical severity' above and 'Definitions of disease extent' above and 'Colonoscopy' above.)
Ulcerative proctitis or proctosigmoiditis

Initial approach — Topical 5-aminosalicylic acid (5-ASA) medications are first-line treatment in those who are willing to use rectal therapy. 5-ASA suppositories
and/or enemas given rectally induce remission in more than 90 percent of patients with mild to moderate proctitis or proctosigmoiditis [12-18]. Remission rates as
high as 93 percent have been reported with mesalamine enemas [14,17]. Furthermore, they can maintain remission in approximately 75 percent of patients. Topical
therapies also provide a quicker response time than oral preparations and typically require less frequent dosing [2].

5-ASA agents are widely available as suppositories or enemas (table 1). 5-ASA foam and gel preparations, available in many countries around the world, are not
available in the United States [19,20]. Enemas reach the proximal sigmoid colon and splenic flexure in virtually all patients who are able to retain them [21]. In contrast,
foam preparations generally reach only the mid-sigmoid colon [22], while suppositories are effective only in the distal 5 to 8 cm of the rectum.

Topical 5-ASA medications are preferred over topical steroids in those who are willing to use topical therapy. A meta-analysis of seven trials concluded that 5-ASA
enemas were significantly superior to corticosteroid enemas for the induction of remission and improving endoscopic and histologic severity (odds ratio [OR] 2.4, 1.9,
and 2.0, respectively) [23]. A second meta-analysis concluded that the efficacy and side effect profile of topical mesalamine were dose-dependent and superior to oral
therapies and topical steroids. Topical 5-ASA therapy was also associated with lower overall patient costs [24]. The side effects of 5-ASA medications are discussed
separately. (See "Sulfasalazine and 5-aminosalicylates in the treatment of inflammatory bowel disease", section on 'Side effects'.)

For patients with mild to moderate disease confined to the distal 5 to 8 cm of rectum, we recommend treatment with mesalamine suppository twice daily (table 1)
[25]. Although there are data to suggest that once daily dosing of a 5-ASA suppository may be sufficient [26], we find that twice daily administration of topical
medications is often needed initially to treat severe urgency and tenesmus.

For patients with mildly to moderately active disease that involves greater than 8 cm of distal rectum, or the rectum plus sigmoid colon (proctosigmoiditis), we begin
treatment with 5-ASA enemas given twice daily in addition to 5-ASA suppositories twice daily (table 1).

Patients who cannot retain enemas due to rectal irritability should be treated with 5-ASA foam preparations where available.

Symptomatic improvement and a decrease in bleeding can be seen within a few days. However, complete healing usually requires four to six weeks or longer, and we
recommend continued treatment for six to eight weeks followed by a gradual taper and discontinuation as tolerated. (See 'Maintenance therapy' below.)

Subsequent and alternative approaches — Other treatment approaches may be required for patients whose symptoms do not respond to topical treatment with 5-
ASA medications, who cannot tolerate topical 5-ASA medications, or who cannot tolerate topical therapy in general:

● Patients who are unwilling or unable to tolerate topical medications can be treated with oral 5-ASA medications alone (table 1). Although oral therapy alone is
effective in the induction of remission in patients with proctitis and proctosigmoiditis, response rates are lower than topical therapy alone [27].

● Patients who cannot tolerate topical 5-ASA medications should be treated with steroid suppositories for the induction of remission, if ulcerative proctitis involves
5 to 8 cm of the distal rectum. Steroid foam preparations or enemas twice daily in combination with steroid suppositories twice daily should be used if the colitis
involves greater than 8 cm of the rectum or the sigmoid colon (table 1) [28-31]. A response is usually seen three to four weeks. In patients with a clear
improvement in symptoms, topical steroid treatment can be tapered gradually to a nightly regimen. (See "Sulfasalazine and 5-aminosalicylates in the treatment of
inflammatory bowel disease", section on 'Side effects'.)

● For patients who do not respond to topical 5-ASA medications alone in four to six weeks, a combination of topical 5-ASA and topical steroids should be used [31].
However, this strategy is supported by limited evidence from one controlled trial in which patients treated with beclomethasone dipropionate and 5-ASA enemas
had higher rates of clinical, histologic, and endoscopic improvement after four weeks of treatment compared with patients who used single-agent therapy [32].

● Patients who do not have an adequate response to topical therapy should be treated with the combination of oral 5-ASA and topical 5-ASA enemas or
suppositories (table 1) [27,33]. Controlled trials have demonstrated the efficacy of both sulfasalazine and oral forms of 5-ASA in the induction and maintenance
of remission in mildly to moderately active ulcerative colitis [34-43]. In one randomized trial, for example, 4.8 g/day of oral 5-ASA was significantly more likely than
placebo to induce complete (24 versus 5 percent) or partial remission (50 versus 13 percent) in patients with mild to moderate ulcerative colitis [34]. We suggest
the use of oral 5-ASAs to sulfasalazine, except in patients with arthritis associated with IBD, because of their better side effect profile. (See "Sulfasalazine and 5-
aminosalicylates in the treatment of inflammatory bowel disease", section on 'Side effects' and "Treatment of arthritis associated with inflammatory bowel
disease", section on 'Treatment approach'.)

In patients with mild symptoms, oral 5-ASA medications should be started at the lower dose and increased to the maximum tolerated dose in patients who remain
symptomatic (table 1). Patients with moderate symptoms, those with previous steroid use, those with frequent relapses, and those previously treated with oral
mesalamine, rectal therapy, or multiple medications are more likely to benefit from a higher dose [44,45].

Oral mesalazine generally acts in two to four weeks [27]. Patients who fail to respond to combination therapy with oral 5-ASA and topical 5-ASA/steroids require
treatment with oral glucocorticoids, as discussed under left-sided colitis below. (See 'Subsequent approach' below and 'Management of persistent symptoms' below.)

Maintenance therapy — Maintenance therapy is not recommended in patients with a first episode of mild ulcerative proctitis that has responded promptly to
treatment. Many such patients may continue for long periods of time without a relapse and, if it does occur, the response to therapy is often prompt and complete.

Maintenance therapy is recommended in patients with ulcerative proctitis who have more than one relapse a year and in all patients with proctosigmoiditis [46].
Discontinuation of medication in these patients should only be considered if they have been in remission for two years and are averse to taking medication [46].

For patients on topical therapy for induction of remission, we recommend a maintenance regimen of one 5-ASA suppository in patients with proctitis and 5-ASA
enema every night in patients with proctosigmoiditis (table 1) [47-51]. In our experience, patients treated with less frequent maintenance therapy (every other day)
often have poor compliance and risk relapse; we therefore rarely recommend a maintenance regimen less frequent than one every night [52]. Steroid enemas should
be avoided for the maintenance of remission as their efficacy has not been established and they may be associated with steroid side effects [53].

Patients who require an oral 5-ASA to achieve remission or have multiple relapses on topical therapy should be continued on oral 5-ASAs to maintain remission (table
1). Patients with frequent relapses may benefit from a higher dose of maintenance therapy [43]. A systematic review estimated that oral 5-ASA medications were
associated with more than a 50 percent decrease in the risk of relapse compared with placebo [53].

Left-sided colitis, extensive colitis, and pancolitis — Patients with mildly or moderately active left-sided colitis and pancolitis benefit most from combination therapy
with oral 5-ASA medications, 5-ASA or steroid suppositories, and 5-ASA or steroid enemas or foam (table 1) [54].

Initial approach — Combination of oral plus rectal 5-ASA has been associated with a higher rate and a reduced time to remission compared with either therapy
alone [27,54]. In a placebo-controlled trial, 127 ambulatory patients with mild/moderate extensive ulcerative colitis received 4 g/day oral mesalamine for eight weeks
[54]. During the initial four weeks, they additionally received an enema at bedtime containing 1 g of mesalamine or placebo. Remission rates were higher in patients
treated with oral and topical mesalamine compared to oral mesalamine alone both at four weeks (44 versus 34 percent) and eight weeks (64 versus 43 percent). The
increased response with combination therapy may be due to the additive effects of oral plus rectal 5-ASA, since the efficacy of 5-ASA is dose-dependent.
A number of different formulations of oral 5-ASA have been developed that permit site-specific, targeted delivery of higher concentrations of 5-ASA. All
mesalamine preparations appear to be equally effective [55-59]. However, a 2009 meta-analysis suggested that balsalazide may be marginally more effective than
mesalamine in the induction of remission, but not in rates of relapse or adverse events [60]. (See "Sulfasalazine and 5-aminosalicylates in the treatment of
inflammatory bowel disease".)

Oral 5-ASA medications can be started at the lowest dose (table 1). In patients who remain symptomatic despite combination therapy (oral 5-ASA and topical
5-ASA/steroids), the dose of oral 5-ASA medications should be increased to the maximum tolerated dose [61].

In addition to oral 5-ASA, we recommend treatment with 5-ASA enemas given twice daily in addition to 5-ASA suppositories twice daily (table 1). Patients who cannot
retain enemas due to rectal irritability should be treated with 5-ASA foam preparations where available. These patients may have an improvement in urgency or
tenesmus with topical treatment aimed at the rectum despite also having more proximal disease [62].

5-ASA medications exert their effect in two to four weeks and are effective in 40 to 80 percent of patients [24,63]. Patients who do not respond in two weeks should
be treated with topical rectal therapy with steroid-containing foam twice daily and/or suppositories twice daily combined with oral 5-ASA therapy.

Subsequent approach — For patients with mild to moderate ulcerative colitis who do not tolerate or who have an inadequate response to the combination of oral 5-
ASA and topical 5-ASA/steroids within two to four weeks, we suggest multimatrix (MMX) budesonide prior to the use of other oral glucocorticoids (table 1).
Budesonide-MMX uses colonic release technology to extend the application of budesonide throughout the colon. In two large randomized trials, budesonide at a dose
of one 9 mg daily for eight weeks was significantly more effective in inducing endoscopic and clinical remission in patients with mild to moderate active ulcerative
colitis as compared with placebo [64,65]. There were no significant steroid-related side effects [64,65].

In patients with severe symptoms and those who fail to respond to budesonide-MMX, we suggest oral prednisone. Oral glucocorticoids are highly effective in inducing
remission in patients with active ulcerative colitis [12,64,66,67]. In one study, oral prednisolone induced remission in 77 percent of 118 patients with mild to moderate
disease within two weeks, compared with 48 percent treated with sulfasalazine [68]. Prednisone is usually effective within 10 to 14 days, after which the dose can be
tapered gradually. (See 'Maintenance therapy' below.)

Patients who have an inadequate response to glucocorticoids should be carefully evaluated to determine the cause for persistent symptoms (see 'Management of
persistent symptoms' below).

Maintenance therapy — Maintenance therapy is recommended in all patients with left-sided colitis, pancolitis, or extensive colitis [46]. 5-ASA medications are
highly effective in the maintenance of remission in patients with ulcerative colitis [69-74]. In a 2011 meta-analysis of 11 randomized controlled trials, the risk of
relapse was significantly lower in patients with quiescent ulcerative colitis treated with 5-ASAs as compared with placebo (relative risk 0.65, 95% CI 0.55-0.76) [74].
Combination therapy with oral and intermittent rectal therapy may be better than oral therapy alone for maintaining remission [33].

After an adequate clinical response and/or remission has been achieved, usually in six to eight weeks, oral 5-ASAs should be continued to maintain remission (table
1). In our experience, a dose of at least 3 g/day is efficacious in maintaining remission, but in some patients, tapering the dose below 3 to 3.6 g/day can lead to earlier
relapse. Patients with exacerbations on lower maintenance doses will often require higher doses to prevent recurrence [43].

The frequency of 5-ASA enemas and/or suppositories can be gradually reduced from twice daily to once daily for long-term maintenance therapy. In our experience,
patients treated with less frequent maintenance therapy (every other day) often have poor compliance and risk relapse. Steroid enemas should be avoided for the
maintenance of remission as their efficacy has not been established and they may be associated with steroid side effects [53].

Although maintenance therapy with budesonide-MMX has not yet been proven, additional eight-week courses can be given for recurring episodes of active, mild to
moderate ulcerative colitis. Oral glucocorticoids including prednisone should not be used for maintenance of remission, since they have not been proven to be
beneficial [64,75]. Glucocorticoids should be tapered after the patient has been stable for two to four weeks. Steroids should be tapered over eight weeks by
decreasing the dose by 5 to 10 mg every week until a daily dose of 20 mg is reached, and then by 2.5 mg every week [76]. More rapid reduction has also been
associated with early relapse and may be associated with adrenal insufficiency [46]. (See "Major side effects of systemic glucocorticoids" and "Glucocorticoid
withdrawal".)

If glucocorticoids cannot be tapered to less than 10 mg daily within three months of starting steroids without recurrent disease, or if relapse occurs within three
months of stopping glucocorticoids, patients are considered to have steroid-dependent ulcerative colitis [77]. Such patients should be carefully evaluated to determine
the cause of persistent symptoms. (See 'Management of persistent symptoms' below and "Approach to adults with steroid-refractory and steroid-dependent ulcerative
colitis", section on 'Steroid-dependent ulcerative colitis'.).

MANAGEMENT OF PERSISTENT SYMPTOMS — Despite the approaches described above, some patients continue to have severe gastrointestinal symptoms. Patients
with continued symptoms should be carefully reassessed, paying specific attention to the type of ongoing symptoms, the degree to which symptoms have improved
or worsened, and compliance with medications.

Reassessment of the extent of disease is indicated if a patient has a recurrence of symptoms after initial improvement that does not mimic the initial presentation.
(See "Endoscopic diagnosis of inflammatory bowel disease", section on 'Role in differential diagnosis'.)

Patients who fail to respond fall into the following categories:

● Those whose symptoms are not due to inflammatory bowel disease. These patients may have an alternative or concomitant diagnosis. (See 'Pretreatment
evaluation' above.)

It is important to recognize that some symptoms in patients with chronic ulcerative colitis are not directly due to the underlying inflammatory process. Many
patients have both inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS). (See "Irritable bowel syndrome in patients with inflammatory bowel
disease" and "Nutrition and dietary management for adults with inflammatory bowel disease", section on 'Nutrition and dietary management'.)

● Patients who are noncompliant or incompletely compliant with therapy [78]. Compliance with medications and enemas in particular should be sought, as many
patients have difficulty with retention of enemas. Such patients can be treated with topical steroid preparations in the form of foams, and steroid-containing
suppositories can be useful in patients with severe rectal symptoms of urgency and tenesmus. (See 'Ulcerative proctitis or proctosigmoiditis' above.).

● Regardless of the extent of colonic involvement, some patients remain symptomatic despite optimal doses of oral 5-ASA drugs, topical therapy with either 5-ASA
or steroids, and systemic glucocorticoids.

Patients without a meaningful clinical response to glucocorticoids up to doses of prednisone 40 to 60 mg/day (or equivalent) within 30 days for oral therapy or 7
to 10 days for intravenous therapy are considered to have steroid-refractory disease. For patients with steroid-refractory ulcerative colitis, additional medical
therapy with cyclosporine as a short-term "bridge" to therapy with longer acting medications (AZA or 6-MP) or an anti-tumor necrosis factor (anti-TNF) agent
should be considered. The management of patients with steroid-refractory ulcerative colitis is discussed in detail separately. (See "Approach to adults with
steroid-refractory and steroid-dependent ulcerative colitis", section on 'Steroid-refractory ulcerative colitis'.)

SYMPTOMATIC TREATMENT — Concomitant symptomatic treatment for diarrhea and abdominal pain may be used for a short duration (7 to 10 days) only while
waiting for anti-inflammatory medications to take effect in patients with mild ulcerative colitis symptoms and no signs of systemic toxicity.
● In patients who have mild intermittent diarrhea without signs of systemic toxicity, antidiarrheal agents may be beneficial, particularly at night to decrease the
frequency of nocturnal episodes. (See 'Assessment of clinical severity' above.) Loperamide is preferred because of its safety and efficacy [79].

In the author’s experience, bulk agents such as psyllium or methylcellulose or pectin may also be helpful while avoiding the risk of precipitating toxic megacolon.

● Abdominal cramping in patients with mildly active ulcerative colitis without signs of systemic toxicity can be relieved by anticholinergic medications such as
propantheline, dicyclomine, and hyoscyamine sulfate. (See 'Assessment of clinical severity' above.). However, systemic side effects are common since these
agents do not selectively affect the intestine.

Opiates should be avoided because they can mask the signs and symptoms of an acute abdomen, and their addiction potential. Nonsteroidal antiinflammatory
drugs should be avoided because they can exacerbate IBD.

HEALTH MAINTENANCE — It is important to consider routine health maintenance, including screening and prevention of other diseases as well as monitoring for side
effects of therapy in patients with inflammatory bowel disease (IBD). A clinical guideline issued by the American College of Gastroenterology addresses preventive
care in IBD and those recommendations are reflected in the subsequent discussion [80].

Immunization — Patients with IBD are at increased risk for infections due to their underlying disease, malnutrition, surgery, or immunosuppressive medications [81-
83]. Routine vaccination status should be reviewed at the time of diagnosis, and patients should be immunized in accordance with guidelines (figure 1). Regardless of
immunosuppression, all patients should be vaccinated for influenza and pneumococcal infection. Live vaccines (eg, MMR, varicella) are contraindicated (figure 2) in
patients who have been on immunosuppressive therapy within the last three months or who are planning to start immunosuppressive therapy within the next six
weeks [84]. If live vaccines are required, they should be administered 6 to 12 weeks prior to the initiation of immunosuppression. The herpes zoster vaccine should be
given to all non-immunosuppressed IBD patients over the age of 50 [80]. We also suggest the vaccine for patients who are on low dose immunosuppression (ie,
methotrexate <0.4 mg/kg/week, azathioprine <3.0 mg/kg/day, or 6-mercaptopurine <1.5 mg/kg/day) [85]. The herpes zoster vaccine is contraindicated in patients on
biologic therapy. We also avoid the vaccine in patients planning to start a biologic within the next one to three months.

Patients should be screened for hepatitis B before initiating anti-TNF therapy, and individuals who are seronegative should be vaccinated for hepatitis B [86]. (See
"Standard immunizations for nonpregnant adults", section on 'Immunization schedule for nonpregnant adults'.)

Cancer screening

Colorectal cancer — Patients with IBD are at increased risk for colorectal cancer (CRC) and should undergo CRC screening with colonoscopy based on the extent
and duration of their disease [87-95]. (See "Surveillance and management of dysplasia in patients with inflammatory bowel disease", section on 'Guidelines from
major societies'.)

Cervical cancer — The prevalence of abnormal Papanicolaou smears is higher in women with IBD on corticosteroids and immunosuppressants [96]. It is important
for clinicians to emphasize the importance of annual cervical cancer screening for women with IBD on immunosuppressive therapy because compliance with cervical
cancer screening tends to be low in women with IBD [97]. Annual screening for cervical cancer should be recommended for women with IBD on immunosuppressive
therapy [80]. (See "Screening for cervical cancer".)

Skin cancer — All IBD patients who have taken, are currently taking, or are planning to start immunomodulators or biologic therapy should undergo annual skin
examination by a dermatologist [80,98]. Both melanoma and nonmelanoma skin malignancies are associated with therapies used for IBD. Nonmelanoma skin cancer
is associated with past or current use of 6-MP/azathioprine. Patients should be advised to avoid excessive sun exposure and use a high-strength sunscreen and sun
protective measures [31]. (See "Dermatologic and ocular manifestations of inflammatory bowel disease", section on 'Rare dermatologic diseases' and "Selection of
sunscreen and sun-protective measures", section on 'Selection of sunscreen products'.)

Osteoporosis screening — Patients with IBD are at increased risk for bone loss [99]. Screening for osteoporosis with bone mineral density testing should be
performed at the time of diagnosis and periodically thereafter in all IBD patients who meet one of the following criteria: postmenopausal, ongoing corticosteroid
treatment, cumulative prior use of corticosteroids exceeding three months, history of low-trauma fractures, or age over 60 years [80]. The frequency is determined by
established guidelines for the general population. (See "Screening for osteoporosis", section on 'Society guideline links'.)

IBD patients on glucocorticoids (any dose with an anticipated duration of ≥3 months) should maintain a total calcium intake of 1200 mg/day and vitamin D intake of
800 international units/day through either diet and/or supplements. Treatment with bisphosphonates in patients with IBD, based on age, gender, and the presence of
existing osteoporosis, is discussed in detail separately. (See "Prevention and treatment of glucocorticoid-induced osteoporosis", section on 'Candidates for
pharmacologic therapy'.)

Anxiety/depression screening — Many IBD patients suffer from anxiety and depression secondary to their disease process and should be screened for these
conditions [100-103]. (See "Screening for depression in adults", section on 'Screening instruments'.).

Laboratory monitoring — Periodic laboratory monitoring is necessary to detect complications associated with IBD and side effects of medical therapy.

● Anemia – Approximately 35 to 90 percent of adults with IBD are iron deficient. Other potential causes of anemia in patients with IBD include anemia of chronic
disease, vitamin B12 deficiency, folic acid deficiency, or drug-induced anemia (eg, in patients treated with sulfasalazine or thiopurines). (See "Nutrient deficiencies
in inflammatory bowel disease".)

In patients with IBD, hematocrit should be measured every 6 to 12 months [31]. In patients with anemia or those with low MCV, ferritin, transferrin saturation, and
C-reactive protein (CRP) should also be checked. The CRP is important in the interpretation of the ferritin level, as ferritin is an acute phase reactant. Ferritin levels
less than 100 mg/L are suggestive of iron deficiency. (See "Causes and diagnosis of iron deficiency and iron deficiency anemia in adults" and "Anemia of chronic
disease/inflammation", section on 'Concomitant iron deficiency'.)

● Side effects of therapy – For patients on 5-ASA agents, serum creatinine should be measured at 6 and 12 months after initiation of therapy and then annually
[104]. For patients on 6-mercaptopurine/azathioprine, weekly blood monitoring (ie, hemoglobin, white blood cell count, platelet count, liver blood tests [serum
aminotransferases and total bilirubin], and amylase) should be performed for the first month or until the maintenance dose is reached. Monitoring should be
continued for the duration of therapy and performed at least every three months. (See "Approach to adults with steroid-refractory and steroid-dependent
ulcerative colitis", section on 'Cyclosporine' and "Overview of azathioprine and mercaptopurine use in inflammatory bowel disease", section on 'Dosing and
monitoring'.)

● Disease activity – The stool marker, calprotectin, may be used to monitor disease activity in patients with IBD. A systematic review of six studies of 552 IBD
(mostly UC) patients in remission showed that ≥2 elevated calprotectin measurements corresponded to a 53 to 83 percent probability of relapse within the next
two to three months [105].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately.
(See "Society guideline links: Ulcerative colitis in adults".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education
pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition.
These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer,
more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and
are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient
education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: Ulcerative colitis in adults (The Basics)")

● Beyond the Basics topics (see "Patient education: Ulcerative colitis (Beyond the Basics)" and "Patient education: Sulfasalazine and the 5-aminosalicylates
(Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

● Ulcerative colitis is a chronic inflammatory condition characterized by relapsing and remitting episodes of inflammation that involves the rectum and may extend
in a proximal and continuous fashion to involve other portions of the colon. (See 'Introduction' above.)

● When a patient with ulcerative colitis presents with recurrent symptoms, some aspects of the initial evaluation, including laboratory studies and endoscopy, need
to be repeated in order to exclude alternative and/or comorbid conditions as a cause for their symptoms, as well as to assess the current extent of disease
involvement and disease severity in order to best guide treatment. (See 'Pretreatment evaluation' above.)

Ulcerative proctitis or proctosigmoiditis

● In patients with mildly or moderately active proctitis or proctosigmoiditis, we recommend topical 5-aminosalicylic acid (5-ASA) to induce remission (table 1)
(Grade 1A). Suppositories alone are effective in managing proctitis, while patients with proctosigmoiditis require enemas in addition to suppositories. (See 'Initial
approach' above.)

● Alternative treatment approaches may be required for patients who cannot tolerate topical 5-ASA medications, topical therapy in general, or who do not respond
to topical treatment with 5-ASA medications (table 1):

• For patients who cannot tolerate topical 5-ASA medications, we recommend steroid foam preparations and steroid suppositories (Grade 1B).

• For patients unwilling or unable to tolerate any topical medication, we recommend oral 5-ASA medications (Grade 1A).

• For patients who do not respond to topical 5-ASA medications, we suggest combination topical 5-ASA and steroid foam preparation (Grade 2B).

• For patients who do not respond to topical medications, we recommend combination therapy with oral and topical 5-ASA agents and topical steroids (Grade
1A).

● For maintenance of remission in patients who have more than one relapse a year and in all patients with proctosigmoiditis, we recommend 5-ASA enemas (table
1) (Grade 1A). Patients who required oral 5-ASAs to achieve remission or who have multiple relapses on topical therapy should be continued on oral 5-ASAs to
maintain remission. (See 'Maintenance therapy' above.)

Left-sided colitis, extensive colitis, or pancolitis

● In patients with mildly or moderately active left-sided colitis/extensive/pancolitis, we recommend combination therapy with oral 5-ASA medications, rectal 5-ASA
or steroid suppositories, and 5-ASA or steroid enemas or foam preparations (table 1) (Grade 1A). (See 'Initial approach' above.)

● In patients who fail to respond to combination therapy with oral 5-ASA medications and topical 5-ASA and steroids, we recommend oral glucocorticoids (table 1)
(Grade 1B). (See 'Subsequent approach' above.)

● We recommend maintenance therapy with combination oral and topical 5-ASA therapy (table 1) (Grade 1A). After an adequate clinical response and/or remission
has been achieved, the dose of oral 5-ASA should be continued to maintain remission and topical 5-ASA therapy can be tapered to once a day. Glucocorticoids
should be tapered after the patient has been stable for two to four weeks. (See 'Maintenance therapy' above.)

Patients with persistent symptoms despite glucocorticoids or steroid-dependent ulcerative colitis should be carefully evaluated to assess medication
compliance, rule out other concomitant diseases, and to determine the need for additional medical therapy. (See 'Management of persistent symptoms' above.)

● It is important to consider health maintenance issues in patients with inflammatory bowel disease (IBD). This includes vaccination to prevent infections,
screening for cancer and anxiety/depression, prevention of and monitoring for bone loss, and laboratory monitoring for complications of IBD and medication side
effects. (See 'Health maintenance' above.)

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Topic 4051 Version 31.0


GRAPHICS

Medical therapy of active ulcerative colitis

Role Medication Trade name (United States or as noted) Daily dose

Induction of remission Topical (rectal) mesalamine*

Suppository Canasa 1 gram (one suppository) twice daily

Retention enema Rowasa 4 grams (one 60 mL unit) twice daily

Topical (rectal) glucocorticoids

Hydrocortisone suppository Proctocort, Hemril 30 mg (one suppository) twice daily

Hydrocortisone aerosol foam 10 percent Cortifoam 90 mg (one applicatorful) twice daily

Hydrocortisone enema Cortenema, Colocort 100 mg (one 60 mL unit) twice daily

Oral 5-aminosalycylic acid (5-ASA) derivatives

Sulfasalazine Azulfidine, Salazopyrin ¶ 4 to 6 grams per day in four divided doses

Mesalamine*

Delayed release enteric coated tablet Asacol ¶, Asacol HD 2.4 to 4.8 grams daily in three divided doses

Capsule containing delayed release enteric Delzicol 2.4 to 4.8 grams daily in three divided doses
coated tablet

Delayed and extended release tablet, Lialda, Mezavant ¶ 2.4 to 4.8 grams daily once daily
multimatrix (MMX)

Capsule containing delayed release enteric Apriso 1.5 to 4.5 grams once each morning
coated granules

Controlled release capsule Pentasa 2 to 4 grams daily in four divided doses

Mesalamine pellets Salofalk ¶ 1.5 to 4 grams daily in one to three divided doses

Pentasa sachet ¶ 2 to 4 grams daily in two to four divided doses

Olsalazine capsule Dipentum 2 to 3 grams daily in two to four divided doses

Balsalazide capsule Colazal 2.25 to 6.75 grams daily in three divided doses

Balsalazide tablet Giazo 2.2 to 6.6 grams daily in two divided doses

Glucocorticoids

Budesonide delayed and extended release Uceris 9 mg once each morning for eight weeks
tablet, multimatrix (MMX)

Prednisone or oral prednisolone   40 to 60 mg once each morning or in two divided


doses

Intravenous prednisolone ¶   30 mg IV every 12 hours

Methylprednisolone Solu-Medrol 16 to 20 mg IV every eight hours

Hydrocortisone Solu-Cortef 100 mg IV every eight hours

Maintenance of remission Topical (rectal) mesalamine*

Suppository Canasa 1 gram (1 suppository) at bedtime

Enema Rowasa 2 to 4 grams (30 to 60 mL) at bedtime

Oral 5-aminosalycylic acid (5-ASA) derivatives

Sulfasalazine Azulfidine, Salazopyrin ¶ 4 to 6 grams daily in three or four divided doses

Mesalamine*

Delayed release enteric coated tablet Asacol ¶, Asacol HD 1.6 to 2.4 grams daily in one to three divided
doses (depending upon preparation)

Capsule containing delayed release enteric Delzicol 1.6 to 2.4 grams daily in one to three divided
coated tablet doses

Delayed and extended release tablet, Lialda, Mezavant ¶ 2.4 grams once daily
multimatrix

Capsule containing delayed release enteric Apriso 1.5 to 3 grams once each morning
coated granules

Controlled release capsule Pentasa 1.5 to 4 grams daily in four divided doses

Mesalamine pellets Salofalk ¶ 0.75 to 4 grams daily in one to three divided


doses

Pentasa sachet ¶ 1.5 to 4 grams once daily

Olsalazine capsule Dipentum 1 gram daily in two divided doses

Balsalazide capsule Colazal 2.25 to 6.75 grams daily in three divided doses

Balsalazide tablet Giazo 2.2 to 6.6 grams daily in two divided doses

Sulfasalazine and mesalamine (Delzicol, Asacol, Pentasa, and Lialda) are approved by the US Food and Drug Administration (FDA) for treatment and maintenance of remission of active ulcerative colitis;
mesalamine (Asacol HD) and balsalazide (Colazal, Giazo) are approved for treatment of active ulcerative colitis (approval of Giazo is limited to male patients), while olsalazine (Dipentum) is approved for
maintenance therapy in patients who are allergic to sulfasalazine. Encapsulated mesalamine granules (Apriso) is approved for maintenance of remission by the US FDA.

5-ASA: 5-aminosalicylate; IV: intravenous; US: United States.


* Mesalamine is US generic name. Mesalazine is an international generic (nonproprietary) name.
¶ Not available in US. Trade names shown are for products commonly available in areas other than US including Canada, United Kingdom, and Europe.

Data courtesy of authors with additional data from: Ordás I, Eckmann L, Talamini M, et al. Ulcerative colitis. Lancet 2012; 380:1606.

Graphic 86774 Version 7.0


Recommended immunization schedule for adults aged 19 years or older by age group - United States, 2018

* Influenza vaccines
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html
General information:
Administer one dose of age-appropriate inactivated influenza vaccine (IIV) or recombinant influenza vaccine (RIV) annually.
NOTE: Live attenuated influenza vaccine (LAIV) is not recommended for the 2017 to 2018 influenza season. A list of currently available
influenza vaccines is available at www.cdc.gov/flu/protect/vaccine/vaccines.htm.
Special populations:
Administer age-appropriate IIV or RIV to:
Pregnant women.
Adults with hives-only egg allergy.
Adults with egg allergy other than hives (eg, angioedema or respiratory distress): Administer IIV or RIV in a medical setting under
supervision of a health care provider who can recognize and manage severe allergic conditions.
¶ Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/tdap-td.html
General information:
Administer to adults who previously did not receive a dose of Tdap as an adult or child (routinely recommended at age 11 to 12 years) one
dose of Tdap, followed by a dose of Td booster every 10 years.
Information on the use of Tdap or Td as tetanus prophylaxis in wound management is available at
www.cdc.gov/mmwr/preview/mmwrhtml/rr5517a1.htm.
Special populations:
Pregnant women: Administer one dose of Tdap during each pregnancy, preferably in the early part of gestational weeks 27 to 36.
Δ Measles, mumps, and rubella (MMR) vaccine
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/mmr.html
General information:
Administer one dose of MMR vaccine to adults with no evidence of immunity to measles, mumps, or rubella.
Evidence of immunity is:
Born before 1957 (except for health care personnel, refer below).
Documentation of receipt of MMR.
Laboratory evidence of immunity or disease.
Documentation of a health care provider-diagnosed disease without laboratory confirmation is not considered evidence of immunity.
Special populations:
Pregnant women and nonpregnant women of childbearing age with no evidence of immunity to rubella: Administer one dose of MMR (if
pregnant, administer MMR after pregnancy and before discharge from health care facility).
HIV infection and CD4 cell count ≥200 cells/mcL for at least six months and no evidence of immunity to measles, mumps, or rubella:
Administer two doses of MMR at least 28 days apart.
Students in postsecondary educational institutions, international travelers, and household contacts of immunocompromised persons:
Administer two doses of MMR at least 28 days apart (or one dose of MMR if previously administered one dose of MMR).
Health care personnel born in 1957 or later with no evidence of immunity: Administer two doses of MMR at least 28 days apart for measles
or mumps, or one dose of MMR for rubella (if born before 1957, consider MMR vaccination).
Adults who previously received ≤2 doses of mumps-containing vaccine and are identified by public health authority to be at increased risk for
mumps in an outbreak: Administer one dose of MMR.
MMR is contraindicated for pregnant women and adults with severe immunodeficiency.
◊ Varicella (VAR) vaccine
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/varicella.html
General information:
Administer to adults without evidence of immunity to varicella two doses of VAR vaccine four to eight weeks apart if previously received no
VAR-containing vaccine (if previously received one dose of VAR-containing vaccine, administer one dose of VAR vaccine at least four weeks
after the first dose).
Evidence of immunity to varicella is:
United States-born before 1980 (except for pregnant women and health care personnel, refer below).
Documentation of receipt of two doses of VAR vaccine or VAR-containing vaccine at least four weeks apart.
Diagnosis or verification of history of varicella or herpes zoster by a health care provider.
Laboratory evidence of immunity or disease.
Special populations:
Administer two doses of VAR vaccine four to eight weeks apart if previously received no VAR-containing vaccine (if previously received one
dose of VAR-containing vaccine, administer one dose of VAR vaccine at least four weeks after the first dose) to:
Pregnant women without evidence of immunity: Administer the first of the two doses or the second dose after pregnancy and before
discharge from health care facility.
Health care personnel without evidence of immunity.
Adults with HIV infection and CD4 cell count ≥200 cells/mcL: May administer, based on individual clinical decision, two doses of VAR vaccine
three months apart.
VAR vaccine is contraindicated for pregnant women and adults with severe immunodeficiency.
§ Zoster vaccines
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/shingles.html
General information:
Administer two doses of recombinant zoster vaccine (RZV) two to six months apart to adults aged 50 years or older regardless of past
episode of herpes zoster or receipt of zoster vaccine, live (ZVL).
Administer two doses of RZV two to six months apart to adults who previously received ZVL at least two months after ZVL.
For adults aged 60 years or older, administer either RZV or ZVL (RZV is preferred).
Special populations:
ZVL is contraindicated for pregnant women and adults with severe immunodeficiency.
¥ Human papillomavirus (HPV) vaccine
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hpv.html
General information:
Administer HPV vaccine to females through age 26 years and males through age 21 years (males aged 22 through 26 years may be
vaccinated based on individual clinical decision).
The number of doses of HPV vaccine to be administered depends on age at initial HPV vaccination:
No previous dose of HPV vaccine: Administer three-dose series at 0, 1 to 2, and 6 months (minimum intervals: 4 weeks between doses 1
and 2, 12 weeks between doses 2 and 3, and 5 months between doses 1 and 3; repeat doses if given too soon).
Aged 9 to 14 years at HPV vaccine series initiation and received one dose or two doses less than five months apart: Administer one
dose.
Aged 9 to 14 years at HPV vaccine series initiation and received two doses at least five months apart: No additional dose is needed.
Special populations:
Adults with immunocompromising conditions (including HIV infection) through age 26 years: Administer three-dose series at zero, one to
two, and six months.
Adult females and males through age 26 years with immunocompromising conditions (described below), including those with HIV infection,
should receive a three-dose series of HPV vaccine at zero, one to two, and six months.
Men who have sex with men (MSM) through age 26 years: Administer two- or three-dose series depending on age at initial vaccination (refer
above); if no history of HPV vaccine, administer three-dose series at zero, one to two, and six months.
Pregnant women through age 26 years: HPV vaccination is not recommended during pregnancy, but there is no evidence that the vaccine is
harmful and no intervention needed for women who inadvertently receive HPV vaccine while pregnant; delay remaining doses until after
pregnancy; pregnancy testing is not needed before vaccination.
‡ Pneumococcal vaccines
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/pneumo.html
General information:
Administer to immunocompetent adults aged 65 years or older one dose of 13-valent pneumococcal conjugate vaccine (PCV13), if not
previously administered, followed by one dose of 23-valent pneumococcal polysaccharide vaccine (PPSV23) at least one year after PCV13; if
PPSV23 was previously administered but not PCV13, administer PCV13 at least one year after PPSV23.
When both PCV13 and PPSV23 are indicated, administer PCV13 first (PCV13 and PPSV23 should not be administered during the same visit);
additional information on vaccine timing is available at www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf.
Special populations:
Administer to adults aged 19 through 64 years with the following chronic conditions one dose of PPSV23 (at age 65 years or older,
administer one dose of PCV13, if not previously received, and another dose of PPSV23 at least one year after PCV13 and at least five years
after PPSV23):
Chronic heart disease (excluding hypertension).
Chronic lung disease.
Chronic liver disease.
Alcoholism.
Diabetes mellitus.
Cigarette smoking.
Administer to adults aged 19 years or older with the following indications one dose of PCV13 followed by one dose of PPSV23 at least eight
weeks after PCV13, and a second dose of PPSV23 at least five years after the first dose of PPSV23 (if the most recent dose of PPSV23 was
administered before age 65 years, at age 65 years or older, administer another dose of PPSV23 at least five years after the last dose of
PPSV23):
Immunodeficiency disorders (including B- and T-lymphocyte deficiency, complement deficiencies, and phagocytic disorders).
HIV infection.
Anatomical or functional asplenia (including sickle cell disease and other hemoglobinopathies).
Chronic renal failure and nephrotic syndrome.
Administer to adults aged 19 years or older with the following indications one dose of PCV13 followed by one dose of PPSV23 at least eight
weeks after PCV13 (if the dose of PPSV23 was administered before age 65 years, at age 65 years or older, administer another dose of
PPSV23 at least five years after the last dose of PPSV23):
Cerebrospinal fluid leak.
Cochlear implant.
† Hepatitis A (HepA) vaccine
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hepa.html
General information:
Administer to adults who have a specific risk (refer below), or lack a risk factor but want protection, two-dose series of single-antigen HepA
vaccine (Havrix at 0 and 6 to 12 months or Vaqta at 0 and 6 to 18 months; minimum interval: 6 months) or a three-dose series of combined
hepatitis A and hepatitis B (HepA-HepB) vaccine at 0, 1, and 6 months; minimum intervals: 4 weeks between first and second doses, 5
months between second and third doses.
Special populations:
Administer HepA to adults with the following indications:
Travel to or work in countries with high or intermediate HepA endemicity.
MSM.
Injection or noninjection drug use.
Work with HepA virus in a research laboratory or with nonhuman primates infected with HepA virus.
Clotting factor disorders.
Chronic liver disease.
Close, personal contact with an international adoptee (eg, household or regular babysitting) during the first 60 days after arrival in the
United States from a country with high or intermediate endemicity (administer the first dose as soon as the adoption is planned).
Healthy adults through age 40 years who have recently been exposed to HepA virus; adults older than age 40 years may receive HepA
vaccine or HepA-HepB vaccine if HepA immunoglobulin cannot be obtained.
Adults who travel in countries with high or intermediate levels of endemic HepA infection or anticipate close personal contact with an
international adoptee (eg, reside in the same household or regularly babysit) from a country with high or intermediate level of endemic HepA
infection within the first 60 days of arrival in the United States should receive a HepA series.
** Hepatitis B (HepB) vaccine
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hepb.html
General information:
Administer to adults who have a specific risk (refer below), or lack a risk factor but want protection, three-dose series of single-antigen
HepB vaccine or combined HepA-HepB vaccine at zero, one, and six months (minimum intervals: Four weeks between doses 1 and 2 for
HepB vaccine and HepA-HepB vaccine; between doses 2 and 3, eight weeks for HepB vaccine and five months for HepA-HepB vaccine).
Special populations:
Administer HepB vaccine or HepA-HepB vaccine to adults with the following indications:
Chronic liver disease (eg, hepatitis C infection, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, alanine
aminotransferase [ALT] or aspartate aminotransferase [AST] level greater than twice the upper limit of normal).
HIV infection.
Percutaneous or mucosal risk of exposure to blood (eg, household contacts of hepatitis B surface antigen [HBsAg]-positive persons;
adults younger than age 60 years with diabetes mellitus or aged 60 years or older with diabetes mellitus based on individual clinical
decision; adults in predialysis care or receiving hemodialysis or peritoneal dialysis; recent or current injection drug users; health care
and public safety workers at risk for exposure to blood or blood-contaminated body fluids).
Sexual exposure risk (eg, sex partners of HBsAg-positive persons; sexually active persons not in a mutually monogamous relationship;
persons seeking evaluation or treatment for a sexually transmitted infection; and MSM).
Receive care in settings where a high proportion of adults have risks for HepB infection (eg, facilities providing sexually transmitted
disease treatment, drug-abuse treatment and prevention services, hemodialysis and end-stage renal disease programs, institutions for
developmentally disabled persons, health care settings targeting services to injection drug users or MSM, HIV testing and treatment
facilities, and correctional facilities).
Travel to countries with high or intermediate HepB endemicity.
¶¶ Meningococcal vaccines
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/mening.html
Special populations: Serogroups A, C, W, and Y meningococcal vaccine (MenACWY)
Administer two doses of MenACWY at least eight weeks apart and revaccinate with one dose of MenACWY every five years, if the risk
remains, to adults with the following indications:
Anatomical or functional asplenia (including sickle cell disease and other hemoglobinopathies).
HIV infection.
Persistent complement component deficiency.
Eculizumab use.
Administer one dose of MenACWY and revaccinate with one dose of MenACWY every five years, if the risk remains, to adults with the
following indications:
Travel to or live in countries where meningococcal disease is hyperendemic or epidemic, including countries in the African meningitis
belt or during the Hajj.
At risk from a meningococcal disease outbreak attributed to serogroup A, C, W, or Y.
Microbiologists routinely exposed to Neisseria meningitidis.
Military recruits.
First-year college students who live in residential housing (if they did not receive MenACWY at age 16 years or older).
General information: Serogroup B meningococcal vaccine (MenB)
May administer, based on individual clinical decision, to young adults and adolescents aged 16 to 23 years (preferred age is 16 to 18 years)
who are not at increased risk two-dose series of MenB-4C (Bexsero) at least one month apart or two-dose series of MenB-FHbp
(Trumenba) at least six months apart.
MenB-4C and MenB-FHbp are not interchangeable.
Special populations: MenB
Administer two-dose series of MenB-4C at least one month apart or three-dose series of MenB-FHbp at zero, one to two, and six months to
adults with the following indications:
Anatomical or functional asplenia (including sickle cell disease).
Persistent complement component deficiency.
Eculizumab use.
At risk from a meningococcal disease outbreak attributed to serogroup B.
Microbiologists routinely exposed to N. meningitidis.
ΔΔ Haemophilus influenzae type b (Hib) vaccine
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hib.html
Special populations:
Administer Hib vaccine to adults with the following indications:
Anatomical or functional asplenia (including sickle cell disease) or undergoing elective splenectomy: Administer one dose if not
previously vaccinated (preferably at least 14 days before elective splenectomy).
Hematopoietic stem cell transplant (HSCT): Administer three-dose series with doses 4 weeks apart starting 6 to 12 months after
successful transplant regardless of Hib vaccination history.

Reproduced from: Advisory Committee on Immunization Practices (ACIP). Advisory Committee on Immunization Practices Recommended Immunization
Schedule for Adults Aged 19 Years or Older: United States, 2018. Available at: http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-
schedule.pdf (Accessed on February 9, 2018).

Graphic 82634 Version 28.0


Recommended immunization schedule for adults aged 19 years or older by medical condition and other indications - United States, 2018

* Influenza vaccines
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html
General information:
Administer one dose of age-appropriate inactivated influenza vaccine (IIV) or recombinant influenza vaccine (RIV) annually.
NOTE: Live attenuated influenza vaccine (LAIV) is not recommended for the 2017 to 2018 influenza season. A list of currently available influenza vaccines is available at
www.cdc.gov/flu/protect/vaccine/vaccines.htm.
Special populations:
Administer age-appropriate IIV or RIV to:
Pregnant women.
Adults with hives-only egg allergy.
Adults with egg allergy other than hives (eg, angioedema or respiratory distress): Administer IIV or RIV in a medical setting under supervision of a healthcare provider who can recognize and manage severe
allergic conditions.
¶ Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/tdap-td.html
General information:
Administer to adults who previously did not receive a dose of Tdap as an adult or child (routinely recommended at age 11 to 12 years) one dose of Tdap, followed by a dose of Td booster every 10 years.
Information on the use of Tdap or Td as tetanus prophylaxis in wound management is available at www.cdc.gov/mmwr/preview/mmwrhtml/rr5517a1.htm.
Special populations:
Pregnant women: Administer one dose of Tdap during each pregnancy, preferably in the early part of gestational weeks 27 to 36.
Δ Measles, mumps, and rubella (MMR) vaccine
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/mmr.html
General information:
Administer one dose of MMR vaccine to adults with no evidence of immunity to measles, mumps, or rubella.
Evidence of immunity is:
Born before 1957 (except for healthcare personnel, refer below).
Documentation of receipt of MMR.
Laboratory evidence of immunity or disease.
Documentation of a healthcare provider-diagnosed disease without laboratory confirmation is not considered evidence of immunity.
Special populations:
Pregnant women and nonpregnant women of childbearing age with no evidence of immunity to rubella: Administer one dose of MMR (if pregnant, administer MMR after pregnancy and before discharge from
healthcare facility).
HIV infection and CD4 cell count ≥200 cells/mcL for at least six months and no evidence of immunity to measles, mumps, or rubella: Administer two doses of MMR at least 28 days apart.
Students in postsecondary educational institutions, international travelers, and household contacts of immunocompromised persons: Administer two doses of MMR at least 28 days apart (or one dose of MMR if
previously administered one dose of MMR).
Healthcare personnel born in 1957 or later with no evidence of immunity: Administer two doses of MMR at least 28 days apart for measles or mumps, or one dose of MMR for rubella (if born before 1957, conside
MMR vaccination).
Adults who previously received ≤2 doses of mumps-containing vaccine and are identified by public health authority to be at increased risk for mumps in an outbreak: Administer one dose of MMR.
MMR is contraindicated for pregnant women and adults with severe immunodeficiency.
◊ Varicella (VAR) vaccine
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/varicella.html
General information:
Administer to adults without evidence of immunity to varicella two doses of VAR vaccine four to eight weeks apart if previously received no VAR-containing vaccine (if previously received one dose of VAR-contain
vaccine, administer one dose of VAR vaccine at least four weeks after the first dose).
Evidence of immunity to varicella is:
United States-born before 1980 (except for pregnant women and healthcare personnel, refer below).
Documentation of receipt of two doses of VAR vaccine or VAR-containing vaccine at least four weeks apart.
Diagnosis or verification of history of varicella or herpes zoster by a healthcare provider.
Laboratory evidence of immunity or disease.
Special populations:
Administer two doses of VAR vaccine four to eight weeks apart if previously received no VAR-containing vaccine (if previously received one dose of VAR-containing vaccine, administer one dose of VAR vaccine at
least four weeks after the first dose) to:
Pregnant women without evidence of immunity: Administer the first of the two doses or the second dose after pregnancy and before discharge from healthcare facility.
Healthcare personnel without evidence of immunity.
Adults with HIV infection and CD4 cell count ≥200 cells/mcL: May administer, based on individual clinical decision, two doses of VAR vaccine three months apart.
VAR vaccine is contraindicated for pregnant women and adults with severe immunodeficiency.
§ Zoster vaccines
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/shingles.html
General information:
Administer two doses of recombinant zoster vaccine (RZV) two to six months apart to adults aged 50 years or older regardless of past episode of herpes zoster or receipt of zoster vaccine, live (ZVL).
Administer two doses of RZV two to six months apart to adults who previously received ZVL at least two months after ZVL.
For adults aged 60 years or older, administer either RZV or ZVL (RZV is preferred).
Special populations:
ZVL is contraindicated for pregnant women and adults with severe immunodeficiency.
¥ Human papillomavirus (HPV) vaccine
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hpv.html
General information:
Administer HPV vaccine to females through age 26 years and males through age 21 years (males aged 22 through 26 years may be vaccinated based on individual clinical decision).
The number of doses of HPV vaccine to be administered depends on age at initial HPV vaccination:
No previous dose of HPV vaccine: Administer three-dose series at 0, 1 to 2, and 6 months (minimum intervals: 4 weeks between doses 1 and 2, 12 weeks between doses 2 and 3, and 5 months between doses
and 3; repeat doses if given too soon).
Aged 9 to 14 years at HPV vaccine series initiation and received one dose or two doses less than five months apart: Administer one dose.
Aged 9 to 14 years at HPV vaccine series initiation and received two doses at least five months apart: No additional dose is needed.
Special populations:
Adults with immunocompromising conditions (including HIV infection) through age 26 years: Administer three-dose series at zero, one to two, and six months.
Adult females and males through age 26 years with immunocompromising conditions (described below), including those with HIV infection, should receive a three-dose series of HPV vaccine at zero, one to two,
and six months.
Men who have sex with men [MSM] through age 26 years: Administer two- or three-dose series depending on age at initial vaccination (refer above); if no history of HPV vaccine, administer three-dose series at ze
one to two, and six months.
Pregnant women through age 26 years: HPV vaccination is not recommended during pregnancy, but there is no evidence that the vaccine is harmful and no intervention needed for women who inadvertently receiv
HPV vaccine while pregnant; delay remaining doses until after pregnancy; pregnancy testing is not needed before vaccination.
‡ Pneumococcal vaccines
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/pneumo.html
General information:
Administer to immunocompetent adults aged 65 years or older one dose of 13-valent pneumococcal conjugate vaccine (PCV13), if not previously administered, followed by one dose of 23-valent pneumococcal
polysaccharide vaccine (PPSV23) at least one year after PCV13; if PPSV23 was previously administered but not PCV13, administer PCV13 at least one year after PPSV23.
When both PCV13 and PPSV23 are indicated, administer PCV13 first (PCV13 and PPSV23 should not be administered during the same visit); additional information on vaccine timing is available at
www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf.
Special populations:
Administer to adults aged 19 through 64 years with the following chronic conditions one dose of PPSV23 (at age 65 years or older, administer one dose of PCV13, if not previously received, and another dose of
PPSV23 at least one year after PCV13 and at least five years after PPSV23):
Chronic heart disease (excluding hypertension).
Chronic lung disease.
Chronic liver disease.
Alcoholism.
Diabetes mellitus.
Cigarette smoking.
Administer to adults aged 19 years or older with the following indications one dose of PCV13 followed by one dose of PPSV23 at least eight weeks after PCV13, and a second dose of PPSV23 at least five years
after the first dose of PPSV23 (if the most recent dose of PPSV23 was administered before age 65 years, at age 65 years or older, administer another dose of PPSV23 at least five years after the last dose of
PPSV23):
Immunodeficiency disorders (including B- and T-lymphocyte deficiency, complement deficiencies, and phagocytic disorders).
HIV infection.
Anatomical or functional asplenia (including sickle cell disease and other hemoglobinopathies).
Chronic renal failure and nephrotic syndrome.
Administer to adults aged 19 years or older with the following indications one dose of PCV13 followed by one dose of PPSV23 at least eight weeks after PCV13 (if the dose of PPSV23 was administered before ag
65 years, at age 65 years or older, administer another dose of PPSV23 at least five years after the last dose of PPSV23):
Cerebrospinal fluid leak.
Cochlear implant.
† Hepatitis A (HepA) vaccine
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hepa.html
General information:
Administer to adults who have a specific risk (refer below), or lack a risk factor but want protection, two-dose series of single antigen HepA vaccine (Havrix at 0 and 6 to 12 months or Vaqta at 0 and 6 to 18 month
minimum interval: 6 months) or a three-dose series of combined hepatitis A and hepatitis B (HepA-HepB) vaccine at 0, 1, and 6 months; minimum intervals: 4 weeks between first and second doses, 5 months
between second and third doses.
Special populations:
Administer HepA vaccine or HepA-HepB vaccine to adults with the following indications:
Travel to or work in countries with high or intermediate HepA endemicity.
MSM.
Injection or noninjection drug use.
Work with HepA virus in a research laboratory or with nonhuman primates infected with HepA virus.
Clotting factor disorders.
Chronic liver disease.
Close, personal contact with an international adoptee (eg, household or regular babysitting) during the first 60 days after arrival in the United States from a country with high or intermediate endemicity
(administer the first dose as soon as the adoption is planned).
Healthy adults through age 40 years who have recently been exposed to HepA virus; adults older than age 40 years may receive HepA vaccine or HepA-HepB vaccine if HepA immunoglobulin cannot be obtain
Adults who travel in countries with high or intermediate levels of endemic HepA infection or anticipate close personal contact with an international adoptee (eg, reside in the same household or regularly babysit)
from a country with high or intermediate level of endemic HepA infection within the first 60 days of arrival in the United States should receive a HepA series.
** Hepatitis B (HepB) vaccine
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hepb.html
General information:
Administer to adults who have a specific risk (refer below), or lack a risk factor but want protection, three-dose series of single antigen HepB vaccine or combined HepA-HepB vaccine at zero, one, and six month
(minimum intervals: Four weeks between doses one and two for HepB vaccine and HepA-HepB vaccine; between doses two and three, eight weeks for HepB vaccine and five months for HepA-HepB vaccine).
Special populations:
Administer HepB vaccine or HepA-HepB vaccine to adults with the following indications:
Chronic liver disease (eg, hepatitis C infection, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, alanine aminotransferase [ALT] or aspartate aminotransferase [AST] level greater tha
twice the upper limit of normal).
HIV infection.
Percutaneous or mucosal risk of exposure to blood (eg, household contacts of hepatitis B surface antigen [HBsAg]-positive persons; adults younger than age 60 years with diabetes mellitus or aged 60 years
older with diabetes mellitus based on individual clinical decision; adults in predialysis care or receiving hemodialysis or peritoneal dialysis; recent or current injection drug users; healthcare and public safety
workers at risk for exposure to blood or blood-contaminated body fluids).
Sexual exposure risk (eg, sex partners of HBsAg-positive persons; sexually active persons not in a mutually monogamous relationship; persons seeking evaluation or treatment for a sexually transmitted
infection; and MSM).
Receive care in settings where a high proportion of adults have risks for HepB infection (eg, facilities providing sexually transmitted disease treatment, drug-abuse treatment and prevention services,
hemodialysis and end-stage renal disease programs, institutions for developmentally disabled persons, healthcare settings targeting services to injection drug users or MSM, HIV testing and treatment
facilities, and correctional facilities).
Travel to countries with high or intermediate HepB endemicity.
¶¶ Meningococcal vaccines
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/mening.html
Special populations: Serogroups A, C, W, and Y meningococcal vaccine (MenACWY)
Administer two doses of MenACWY at least eight weeks apart and revaccinate with one dose of MenACWY every five years, if the risk remains, to adults with the following indications:
Anatomical or functional asplenia (including sickle cell disease and other hemoglobinopathies).
HIV infection.
Persistent complement component deficiency.
Eculizumab use.
Administer one dose of MenACWY and revaccinate with one dose of MenACWY every five years, if the risk remains, to adults with the following indications:
Travel to or live in countries where meningococcal disease is hyperendemic or epidemic, including countries in the African meningitis belt or during the Hajj.
At risk from a meningococcal disease outbreak attributed to serogroup A, C, W, or Y.
Microbiologists routinely exposed to Neisseria meningitidis.
Military recruits.
First-year college students who live in residential housing (if they did not receive MenACWY at age 16 years or older).
General Information: Serogroup B meningococcal vaccine (MenB)
May administer, based on individual clinical decision, to young adults and adolescents aged 16 to 23 years (preferred age is 16 to 18 years) who are not at increased risk two-dose series of MenB-4C (Bexsero) at
least one month apart or two-dose series of MenB-FHbp (Trumenba) at least six months apart.
MenB-4C and MenB-FHbp are not interchangeable.
Special populations: MenB
Administer two-dose series of MenB-4C at least one month apart or three-dose series of MenB-FHbp at zero, one to two, and six months to adults with the following indications:
Anatomical or functional asplenia (including sickle cell disease).
Persistent complement component deficiency.
Eculizumab use.
At risk from a meningococcal disease outbreak attributed to serogroup B.
Microbiologists routinely exposed to Neisseria meningitidis.
ΔΔ Haemophilus influenzae type b (Hib) vaccine
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hib.html
Special populations:
Administer Hib vaccine to adults with the following indications:
Anatomical or functional asplenia (including sickle cell disease) or undergoing elective splenectomy: Administer one dose if not previously vaccinated (preferably at least 14 days before elective splenectomy
Hematopoietic stem cell transplant (HSCT): Administer three-dose series with doses 4 weeks apart starting 6 to 12 months after successful transplant regardless of Hib vaccination history.

Reproduced from: Advisory Committee on Immunization Practices (ACIP). Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older: United States, 2018. Availab
at: http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf (Accessed on February 8, 2018).

Graphic 62130 Version 16.0


Contributor Disclosures
Richard P MacDermott, MD Nothing to disclose Paul Rutgeerts, MD, PhD, FRCP Consultant/Advisory Boards: Johnson & Johnson; MSD; UCB; AbbVie; Takeda;
Genentech; Bristol-Myers Squibb; Tillotts Pharma; Parexel; Quintiles; Robarts; Amgen/Medimmune/AstraZeneca. Kristen M Robson, MD, MBA, FACG Nothing to
disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process,
and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to
UpToDate standards of evidence.

Conflict of interest policy