What is the treatment for proctitis (inflammation of the rectum)?

From the Guidelines

For the treatment of proctitis, mesalamine suppositories are recommended as the first-line treatment, with a dose of 1-1.5 grams per day, as they have been shown to be more effective than placebo in inducing remission 1.

Treatment Options

• Mesalamine suppositories (1-1.5 grams per day) are the preferred treatment for mild-moderate ulcerative proctitis, due to their superior efficacy compared to rectal corticosteroids in inducing remission 1.
• Rectal corticosteroids, such as budesonide suppositories, may be considered for patients who are refractory to or intolerant of mesalamine suppositories, although their long-term safety and effectiveness are unknown 1.
• Oral 5-ASA therapy may be added for more extensive disease, with a dose of 2-4 grams per day.

Rationale

The American Gastroenterological Association (AGA) suggests using mesalamine suppositories for the treatment of mild-moderate ulcerative proctitis, based on the results of several randomized controlled trials (RCTs) that demonstrated their efficacy in inducing remission 1.

Important Considerations

• The quality of evidence for mesalamine suppositories is moderate, while the evidence for rectal corticosteroids is low due to the lack of direct comparisons with mesalamine suppositories 1.
• Patients who require repeated or prolonged corticosteroid courses should be considered for escalation to biologic therapies and/or immunomodulators 1.

From the FDA Drug Label

Mesalamine delayed-release tablets are an aminosalicylate, and symptoms of salicylate toxicity may include nausea, vomiting, abdominal pain, tachypnea, hyperpnea, tinnitus, and neurologic symptoms (headache, dizziness, confusion, seizures). The mechanism of action of mesalamine is not fully understood, but it appears to have a topical anti-inflammatory effect on the colonic epithelial cells Mucosal production of arachidonic acid metabolites, both through the cyclooxygenase and lipoxygenase pathways, is increased in patients with ulcerative colitis, and it is possible that mesalamine diminishes inflammation by blocking cyclooxygenase and inhibiting prostaglandin production in the colon.

Treat proctitis with mesalamine may be considered as it has a topical anti-inflammatory effect.

• The dosage should be determined based on the patient's condition and medical history.
• Monitoring of the patient's condition and potential side effects is necessary.
• Renal function should be evaluated prior to initiation and periodically while on mesalamine therapy. 2

From the Research

Treatment Options for Proctitis

• Topical 5-aminosalicylates (5-ASA) are effective in treating proctitis, with suppositories being a commonly used formulation 3, 4, 5, 6
• Corticosteroids, such as beclomethasone, can be used to induce remission in patients with proctitis, and may be more effective when combined with 5-ASA 3, 7
• Mesalazine suppositories are a first-line therapy for patients with ulcerative proctitis, due to their high effectiveness and safety 4
• Rectal budesonide foam is an alternative treatment option for distal ulcerative colitis, with a remission rate of approximately 41.2% 7
• Immunomodulators or biological therapy may be considered for refractory patients or those who are steroid-dependent 5

Efficacy of Treatment Options

• Topical 5-ASA has been shown to be superior to placebo for induction and maintenance of clinical remission, as well as induction of endoscopic remission 6
• Combined topical steroids and 5-ASA may be more effective than topical 5-ASA or topical steroids alone for inducing response 3
• Mesalazine suppositories have been shown to be more effective than dose intensification of oral mesalazine for relapsed patients with maintenance dose of oral mesalazine 4

Management of Proctitis

• The short-term goal of treatment is to induce remission, while long-term goals are to maintain remission and prevent disease progression 5
• Topically administered 5-ASA and corticosteroids are effective in the treatment of proctitis, although they may be underused in everyday practice 5
• Alternative medicine can be used complementarily, while experimental approaches are reserved for patients failing conventional medication 5