Ulcerative colitis / Inflammatory bowel disease

BSG Guidelines: Inflammatory bowel disease in adults

Prescribing Notes:

The appropriate mesalazine preparation should be chosen according to the location of disease.
Local therapies using topical treatment will resolve symptoms in most patients who have bloody diarrhoea from rectosigmoid disease, without side effects.
Acute mild to moderate disease affecting the rectosigmoid is treated initially with local application of aminosalicylate. Alternatively, if this is not tolerated or not effective, a local corticosteroid can be considered.
Some systemic absorption of steroid occurs from rectal steroids; prolonged use may lead to adrenal suppression and steroid side effects and should be avoided.
A combination of a local and an oral aminosalicylate can be used in distal colitis if topical treatment fails to adequately control symptoms.
If the patient presents with severe disease (6 or more bloody stools a day and systemic symptoms) urgent admission should be considered and discussion with secondary care is recommended.
Maintenance rectal therapy is an appropriate treatment strategy for rectal disease. Suppositories are the treatment of choice for patients with inflammation confined to the rectum, enemas should be used for more extensive inflammation. Maintenance rectal therapy does not need to be given every day and twice weekly treatments will be sufficient for some patients.

History Notes

15/04/2026

Regional formulary chapter launched.

Oral mesalazine.

Oral and rectal mesalazine in combination.

For inducing remission in patients with mild to moderate ulcerative colitis where 5-ASA treatment is not sufficient.

Prescribing Notes:

A combination of a local and an oral aminosalicylate can be used in disease above the rectosigmoid if topical treatment fails to adequately control symptoms.
If the patient presents with severe disease (6 or more bloody stools a day and systemic symptoms) urgent admission should be considered and discussion with secondary care is recommended.
Aminosalicylates can cause blood disorders; patients should report any unexplained bleeding, bruising, purpura, sore throat, fever or malaise occurring during therapy. A blood count should be performed and the drug stopped immediately if a blood dyscrasia is suspected.
Interstitial nephritis is a rare side effect of mesalazine. Renal function should be measured at start of treatment, at three months of treatment and then annually thereafter.
Patients previously maintained and stable on other aminosalicylates need not be changed to a different brand. If it is necessary to switch a patient to a different brand of mesalazine, the patient should be advised to report any change in symptoms.
Patients previously being prescribed Asacol may be switched to Octasa as they are bioequivalent.
Avoid aminosalicylates (mesalazine, olsalazine, sulfasalazine) in patients allergic to aspirin, and those with renal failure (eGFR < 20ml/minute/1.73m²).
Mild disease extending beyond the rectum can be treated with an oral aminosalicylate alone; a combination of a local and an oral aminosalicylate can be used in proctitis or distal colitis.
The brand should be maintained as per instructions from initiating consultant.
See the Healthcare Improvement Scotland website for details around the use of a Steroid Emergency Card.

History Notes

16/04/2026

Addition of Zyduco XL 1200mg tablets (WoS FC 15/04/2026).

15/04/2026

Regional formulary chapter launched.

Prescribing Notes:

Severe exacerbations of ulcerative colitis require systemic corticosteroids. Patients passing 6 or more bloody stools a day with systemic disturbance should be referred to secondary care urgently.
If there are two or more inflammatory exacerbations in a 12-month period that require treatment with oral corticosteroids, or if remission cannot be maintained by aminosalicylates, patients should be considered for second line medical therapy. Azathioprine and mercaptopurine may be used on specialist advice in selected patients with steroid dependent inflammatory bowel disease as a steroid sparing agent. Specialist can advise on other treatment options.
See the Healthcare Improvement Scotland website for details around the use of a Steroid Emergency Card.

History Notes

15/04/2026

Regional formulary chapter launched.

The order of the medicines below takes into account national guidance, but local practice should also be considered when considering medicine choice.

Infliximab – for inducing remission in patients with mild to moderate ulcerative colitis where 5-ASA treatment is not sufficient.

Prescribing Notes:

Biologic and targeted synthetic DMARDs are reserved for specialist use only for patients with ulcerative colitis in line with national guidance and West of Scotland Formulary decisions (i.e. locally approved health technology assessment approvals and restrictions in line with national guidance).
Refer to local board prescribing guidelines and MHRA Drug Safety Update (April 2023) on Janus Kinase (JAK) Inhibitors.
All biological medicines, including biosimilars, should be prescribed by brand name. Further information for patients, regarding condition and treatments can be found at Crohn’s & Colitis UK.
Ustekinumab may be utilised in preference to infliximab in older patients. Risankizumab and mirikizumab may be utilised in preference to upadacitinib in older patients.

History Notes

15/04/2026

Regional formulary chapter launched.

Purine analogues are not suggested for induction of remission but are suggested for maintenance of remission for patients once remission is achieved. They are also suggested alongside infliximab therapy.

History Notes

15/04/2026

Regional formulary chapter launched.