What is the treatment for ulcerative colitis and proctitis?

From the Guidelines

The treatment for colitis and proctitis should start with mesalamine, either as a suppository for proctitis or as an oral medication for more extensive disease, as recommended by the AGA guidelines 1.

Initial Management

• Mesalamine is the first-line treatment for mild to moderate ulcerative colitis and proctitis, with a recommended dose of 1-4g daily 1.
• For proctitis, a mesalamine 1-g suppository once daily is preferred, but foam or enemas can be used as alternatives 1.
• Topical mesalamine is more effective than topical steroids for proctitis 1.

Moderate to Severe Flares

• Corticosteroids like prednisone may be used for moderate to severe flares to quickly reduce inflammation, with a dose of 40-60mg daily tapered over 8-12 weeks [@Example@].
• The decision to introduce oral steroids depends on the response to and tolerance of 5-ASA, patient preference, and physician practice 1.

Maintenance Therapy

• Immunomodulators such as azathioprine or 6-mercaptopurine can help prevent relapses in patients with frequent flares or those who are steroid-dependent [@Example@].
• There is no recommendation for the use of probiotics or curcumin in patients with mild-moderate ulcerative colitis due to a lack of evidence 1.

Refractory Cases

• Patients with refractory proctitis may require treatment with systemic steroids, immunosuppressants, and/or biologics 1.
• Fecal microbiota transplantation may be considered in the context of a clinical trial for patients with mild-moderate ulcerative colitis without Clostridium difficile infection 1.

From the FDA Drug Label

Ulcerative Colitis: • reducing signs and symptoms, inducing and maintaining clinical remission and mucosal healing, and eliminating corticosteroid use in adult patients with moderately to severely active disease who have had an inadequate response to conventional therapy. (1. 3) The treatment for ulcerative colitis with infliximab (IV) is to reduce signs and symptoms, induce and maintain clinical remission and mucosal healing, and eliminate corticosteroid use in adult patients with moderately to severely active disease who have had an inadequate response to conventional therapy 2.

• Key points:
  • Reducing signs and symptoms
  • Inducing and maintaining clinical remission
  • Mucosal healing
  • Eliminating corticosteroid use However, the FDA drug label does not specifically mention the treatment for proctitis. The FDA drug label does not answer the question for proctitis.

From the Research

Treatment Options for Colitis and Proctitis

• The treatment for colitis and proctitis typically involves the use of oral 5-aminosalicylates (5-ASAs) as first-line therapy in patients with mild to moderate ulcerative colitis (UC) and ulcerative proctitis (UP) 3.
• For patients with more severe illness, steroids with or without 5-ASAs may be used 3.
• Mesalazine suppositories are often used to treat ulcerative proctitis, with oral 5-ASAs being used in combination therapy 3, 4.
• Topical aminosalicylates, such as rectally administered 5-ASA and corticosteroid suppositories, are effective in treating ulcerative proctitis 4, 5.
• The combination of rectally administered 5-ASA enemas and oral 5-ASA agents may be used to treat left-sided colitis and prevent proximal extension of disease 4.

Pharmacotherapy and Management

• Topically administered 5-aminosalicylates (5-ASA) and corticosteroids are effective in the treatment of proctitis, although they may be underused in everyday practice 6.
• Locally administered 5-ASA preparations are more effective than oral compounds 6.
• The combination of topical and oral 5-ASA and steroids should be considered for escalation of treatment 6.
• Refractory patients may require immunomodulators or biological therapy, and alternative medicine can be used complementarily 6.
• Rectal budesonide and mesalamine formulations can be used to treat active ulcerative proctosigmoiditis, with rectal budesonide having a better patient tolerance profile compared to enema formulations 7.

Treatment Approach

• The short-term goal of treatment in UC is to induce remission, while long-term goals are to maintain remission and prevent disease progression 6.
• Maintenance treatment with 5-ASA is indicated in all UC cases to prevent relapse and disease progression 6.
• Proctocolectomy may be considered as a last resort of treatment for patients who are refractory to medical therapy 4, 6.