Gastroenterology Treatment Review Note

History

Marcus Vance is a 34-year-old male with a history of left-sided ulcerative colitis (UC) diagnosed in 2021, presenting for a treatment review. His current general health is fair, though he complains of worsening bloody diarrhea (6-8 BM/day), nocturnal symptoms, and moderate LLQ cramping over the past 4 weeks. He has been maintained on mesalazine (Lialda®) 4.8 g PO daily for 2 years and started budesonide (Uceris®) 9 mg PO daily 3 weeks ago with minimal relief. A flexible sigmoidoscopy on 02/10/2023 demonstrated Mayo 2 pan-left-sided colitis to 40 cm. He reports mild fatigue and urgency, but denies fever, chills, weight loss, arthralgias, or ocular symptoms.

Past Medical History

• Left-sided ulcerative colitis (diagnosed 05/2021)
• Iron deficiency anemia
• Appendectomy (2012)

Investigations

• Flexible sigmoidoscopy (02/10/2023)
• Marked erythema, absent vascular pattern, friability, and erosions from rectum to 40 cm (Mayo endoscopic subscore 2); biopsies negative for CMV.
• Stool studies and blood work: Fecal calprotectin 850 µg/g, C. diff PCR negative, CBC, CMP, CRP 18 mg/L, QuantiFERON-TB Gold negative, Hep B/C serologies negative (04/10/2023)
• Lab results indicate active moderate-to-severe mucosal inflammation without superinfection; infectious screening cleared for biologic therapy.

Impression

Moderate-to-severe active left-sided ulcerative colitis. The patient is experiencing an acute flare refractory to optimized 5-ASA and oral corticosteroid therapy. Given steroid dependency and endoscopic severity, we will transition to biologic therapy with vedolizumab and initiate a prednisone taper for acute bridge relief.

• Left-sided ulcerative colitis, moderate-to-severe flare (Mayo 2)
• Suboptimal response to oral mesalazine and budesonide

Discussed initiating vedolizumab infusions, discontinuing budesonide, starting a short oral prednisone taper, and continuing oral mesalazine. The patient verbalized understanding and agreed with the treatment escalation.

Management Plan

• Escalation to biologic therapy is required to induce and maintain steroid-free mucosal healing given failure of conventional therapy.
• Discontinue budesonide; initiate prednisone bridge; start vedolizumab (Entyvio®); continue mesalazine 4.8 g PO daily.
• Vedolizumab is a humanized monoclonal antibody that specifically binds to the alpha4beta7 integrin, selectively blocking gut-specific lymphocyte trafficking without systemic immunosuppression.
• Selected due to its gut-selective safety profile, favorable efficacy in bio-naive UC patients, and low risk of systemic opportunistic infections.
• Vedolizumab 300 mg IV at weeks 0, 2, and 6, then every 8 weeks thereafter; prednisone 40 mg PO daily for 2 weeks, then taper by 5 mg weekly until discontinued.
• Stop budesonide 9 mg PO daily immediately; start prednisone 40 mg PO daily tomorrow morning; schedule first vedolizumab IV infusion within 1-2 weeks.
• Prior authorization submitted to insurance; prescription sent to Paragon Specialty Pharmacy to coordinate infusion center delivery.
• Repeat CBC, CMP, CRP, and fecal calprotectin at week 8 (prior to the first maintenance dose).
• Flexible sigmoidoscopy in 6 months to assess for mucosal healing.
• Report any worsening abdominal pain, high-volume hematochezia, fever, or signs of infusion reaction immediately.
• Monitor daily stool frequency, presence of blood, and body weight.
• Advised to maintain hydration, consume a low-residue diet during the active flare, and strictly avoid NSAIDs.