What is the diagnosis and treatment for colitis (inflammation of the colon)?

From the Guidelines

For severe active ulcerative colitis, the initial recommended treatment is intravenous steroids, specifically methylprednisolone 60 mg every 24 hours or hydrocortisone 100 mg four times daily, as this approach has been shown to be effective in managing the condition and improving outcomes. The treatment of colitis, particularly ulcerative colitis, depends on the severity of the disease, with mild to moderate cases often managed with 5-aminosalicylates like mesalamine (800-1600mg three times daily) as the first-line treatment 1. However, for moderate to severe flares, corticosteroids such as prednisone (40-60mg daily, tapered over 8-12 weeks) are commonly used, with a strong recommendation for oral corticosteroids like prednisolone 40 mg daily weaning over 6–8 weeks for moderate to severe ulcerative colitis 1.

In cases of severe ulcerative colitis, the definition often relies on criteria such as bloody stool frequency, tachycardia, temperature, anemia, or an elevated erythrocyte sedimentation rate (ESR), with patients having severe UC necessitating hospital admission 1. For these severe cases, intravenous steroids are the preferred initial treatment, with monotherapy with intravenous ciclosporin being an alternative, especially in cases of serious adverse events due to steroids. The use of intravenous fluids, low-molecular-weight heparin for thromboprophylaxis, and correction of electrolyte abnormalities and anemia are also crucial components of the management plan 1.

The goal of treatment is to reduce the inflammatory response, allow the tissue to heal, and improve the quality of life for patients. Regular follow-up with a gastroenterologist is essential for monitoring disease activity and adjusting treatment as needed. In some cases, maintenance therapy with immunomodulators like azathioprine or biologics such as infliximab may be necessary to manage the disease effectively. Patients should also be advised to increase fluid intake, avoid trigger foods, and seek immediate medical attention for severe symptoms like high fever or significant bleeding.

Key considerations in the management of ulcerative colitis include:

• Severity of the disease
• Distribution and pattern of the disease
• Response to previous medications
• Presence of extra-intestinal manifestations
• Age at onset and disease duration
• The need for hospital admission versus outpatient management
• The use of validated indices like the Truelove and Witts criteria to define severe UC 1.

Overall, the management of colitis, especially ulcerative colitis, requires a comprehensive approach that considers the severity of the disease, the patient's overall health, and the potential benefits and risks of different treatment options, with the primary goal of reducing morbidity, mortality, and improving quality of life.

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) Pediatric Ulcerative Colitis: • reducing signs and symptoms and inducing and maintaining clinical remission in pediatric patients with moderately to severely active disease who have had an inadequate response to conventional therapy. (1. 4)

Infliximab (IV) is indicated for the treatment of ulcerative colitis in adult and pediatric patients with moderately to severely active disease who have had an inadequate response to conventional therapy. The goal of treatment is to reduce signs and symptoms, induce and maintain clinical remission, and eliminate corticosteroid use. 2 2 2

From the Research

Definition and Symptoms of Colitis

• Colitis is a chronic inflammatory disease of the colon that typically manifests as diarrhea, abdominal pain, and bloody stool 3.
• Complications, such as colorectal cancer and extraintestinal manifestations, may also develop 3.

Treatment Approaches for Colitis

• Mesalamine is a 5-aminosalicylic acid compound that is the first-line therapy to induce and maintain clinical remission in patients with mild-to-moderate ulcerative colitis 3, 4.
• For patients who are refractory to mesalamine or have more severe disease, steroids, azathioprine/mercaptopurine, cyclosporine, or infliximab may be used to induce and/or maintain remission 3, 5.
• The use of once-daily formulations of mesalamine, such as MMX mesalamine, has led to improved patient adherence to mesalamine therapy 3.

Management of Ulcerative Colitis

• The goals of management are to induce and maintain clinical remission and to screen for complications of the disease 3.
• Optimization of 5-aminosalicylate dosage may be indicated even for quiescent patients with ulcerative colitis if mucosal healing is not obtained, and if patients have multiple risk factors for recurrence 6.
• The discontinuation of 5-aminosalicylate is acceptable when biologics are used 6.

Clinical Trials and Studies

• Clinical trials have confirmed the efficacy and safety of mesalamine in patients with mild to moderate ulcerative colitis 4.
• A randomized controlled trial found that the combination of mesalamine with corticosteroids did not benefit hospitalized patients with acute severe ulcerative colitis more than corticosteroids alone 7.
• However, an exploratory signal for a reduced need for biologics at 90 days in the mesalamine group merits further evaluation 7.