From the Guidelines
The treatment of colitis should be tailored to the individual patient, taking into account the type and severity of the disease, with a focus on reducing inflammation, inducing and maintaining remission, and improving quality of life, as recommended by the most recent guidelines 1.
Treatment Approach
The treatment approach for colitis typically involves a step-up strategy, starting with mild cases and progressing to more severe cases.
- For mild to moderate ulcerative colitis, 5-aminosalicylates (5-ASAs) like mesalamine (doses ranging from 2-4.8g daily) are often first-line treatments, available as oral tablets or rectal formulations for distal disease.
- For more severe cases or when 5-ASAs are insufficient, corticosteroids such as prednisone (40-60mg daily, tapered over 8-12 weeks) may be used for acute flares, as recommended by the British Society of Gastroenterology 1.
- Immunomodulators like azathioprine (2-3mg/kg/day) or 6-mercaptopurine (1-1.5mg/kg/day) are used for maintenance therapy in patients who are steroid-dependent or frequent relapsers.
- For moderate to severe disease or when conventional therapies fail, biologic agents including anti-TNF drugs (infliximab, adalimumab), anti-integrin therapies (vedolizumab), or JAK inhibitors (tofacitinib) may be necessary, as discussed in the AGA clinical practice guidelines 1.
Supportive Care
Supportive care is also important, including:
- Hydration
- Electrolyte replacement
- Dietary modifications
Infectious Colitis
For infectious colitis, specific antimicrobial therapy is directed at the causative organism, such as metronidazole for C. difficile infection, as outlined in the guidelines for the management of inflammatory bowel disease in adults 1.
Recent Developments
Recent studies have highlighted the effectiveness of small molecule therapies, such as ozanimod, for the treatment of ulcerative colitis, providing advantages including oral administration and little to no risk of immunogenicity 1.
Key Considerations
When treating colitis, it is essential to consider the individual patient's needs, taking into account factors such as disease severity, medical history, and patient preferences, as emphasized in the third European evidence-based consensus on diagnosis and management of ulcerative colitis 1.
From the FDA Drug Label
1.3 Ulcerative Colitis RENFLEXIS is indicated for reducing signs and symptoms, inducing and maintaining clinical remission and mucosal healing, and eliminating corticosteroid use in adult patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy. 1.4 Pediatric Ulcerative Colitis RENFLEXIS is indicated for reducing signs and symptoms and inducing and maintaining clinical remission in pediatric patients 6 years of age and older with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy. 2.3 Ulcerative Colitis The recommended dose of RENFLEXIS is 5 mg/kg given as an intravenous induction regimen at 0,2 and 6 weeks followed by a maintenance regimen of 5 mg/kg every 8 weeks thereafter for the treatment of adult patients with moderately to severely active ulcerative colitis. 2.4 Pediatric Ulcerative Colitis The recommended dose of RENFLEXIS for pediatric patients 6 years and older with moderately to severely active ulcerative colitis is 5 mg/kg given as an intravenous induction regimen at 0,2 and 6 weeks followed by a maintenance regimen of 5 mg/kg every 8 weeks.
Treatment of Colitis:
- Infliximab (IV) is indicated for the treatment of ulcerative colitis in adult and pediatric patients.
- The recommended dose for ulcerative colitis is 5 mg/kg given as an intravenous induction regimen at 0,2, and 6 weeks, followed by a maintenance regimen of 5 mg/kg every 8 weeks.
- Infliximab is used to reduce signs and symptoms, induce and maintain clinical remission, and eliminate corticosteroid use in patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy 2.
From the Research
Treatment Options for Colitis
- The treatment of patients with active ulcerative colitis (UC) depends on the severity, localization, and history of IBD medication 3.
- For mild to moderately active UC, treatment with 5-aminosalicylic acid compounds is the first step 3, 4, 5.
- Corticosteroids, such as prednisolone, are used in UC patients with moderate to severe disease activity, but only for remission induction therapy due to side effects associated with long-term use 3, 4.
- Thiopurines are the next step in the treatment of active UC, but monotherapy during induction therapy in UC patients is not preferred due to their slow onset 3.
- In patients with severely active UC refractory to corticosteroids, calcineurin inhibitors such as ciclosporin A (CsA) and tacrolimus are potential therapeutic options 3, 6.
- Monoclonal antibodies (anti-tumor necrosis factor [TNF] agents, vedolizumab) are the last pharmacotherapeutic option for UC patients before surgery becomes inevitable 3.
Maintenance Treatment
- Maintenance treatment is indicated in all UC cases, with 5-ASA compounds suggested as first-line maintenance therapy 4, 5.
- The optimal dose of 5-ASA compounds for maintenance therapy is still under investigation 4.
- Topical compounds are effective for maintenance in distal colitis or proctitis, if accepted by the patients 4.
- Immunosuppressives, especially azathioprine, should be considered in chronically active, steroid-dependent, or resistant patients 4.
Emerging Treatment Strategies
- Historically, medical therapy for UC was limited to corticosteroids, but over the past 1-2 decades, options for medical therapy have expanded to include biologics and small molecules, with more agents actively being developed 7.
- The goals of treatment in UC are to improve quality of life, achieve steroid-free remission, and minimize the risk of cancer 6.
- The choice of treatment depends on disease extent, severity, and the course of the disease 6.