From the Guidelines
Treatment for proctocolitis, specifically ulcerative proctitis, should start with mesalamine suppositories (1g daily) as the first-line therapy, as recommended by the AGA and ECCO guidelines 1. This approach is based on the strong recommendation and moderate quality evidence from the AGA clinical practice guidelines on the management of mild-to-moderate ulcerative colitis, which suggests that mesalamine suppositories are the preferred initial treatment for mild or moderately active proctitis. The following key points support this recommendation:
- Mesalamine suppositories are more effective than topical steroids for inducing symptomatic, endoscopic, and histological remission in patients with proctitis, as shown in a Cochrane systematic review of 38 clinical trials 1.
- Suppositories are more appropriate than enemas in proctitis as they better target the site of inflammation and are more acceptable for patients, with no dose response for topical therapy above a dose of 1 g 5-ASA daily 1.
- Once-daily topical therapy is as effective as divided doses, and low-volume enemas are not inferior to high-volume enemas and may be better tolerated 1. For patients who are intolerant of or refractory to mesalamine suppositories, rectal corticosteroid therapy may be considered as an alternative, although the evidence for this is conditional and based on low-quality evidence 1. In cases of refractory proctitis, systemic steroids, immunosuppressants, and/or biologics may be necessary, and surgery may be considered as a last resort 1. It is essential to note that the treatment approach may vary depending on the severity of the disease, patient preferences, and the physician's practice, and regular follow-up is necessary to monitor response and adjust therapy as needed.
From the FDA Drug Label
- 1 Mechanism of Action 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.
The FDA drug label does not answer the question about proctocolitis treatment.
From the Research
Treatment Options for Proctocolitis
- The treatment for proctocolitis, a type of inflammatory bowel disease, depends on the extent and severity of the disease 2, 3.
- For proctitis, which is a type of ulcerative colitis limited to the rectum, topical 5-aminosalicylic acid (5-ASA) drugs are used as the first line agents 2, 3, 4.
- 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 4.
- Corticosteroids, thiopurines, and anti-TNFα agents may also be used in the treatment of proctocolitis, although their efficacy in ulcerative proctitis has been insufficiently studied 3, 4.
- In cases of refractory proctitis, immunomodulators or biological therapy may be considered 3.
Management of Proctitis
- The management of proctitis involves a step-up approach, starting with topical 5-ASA and escalating to oral 5-ASA and corticosteroids as needed 3.
- Maintenance therapy with 5-ASA is indicated in all cases of ulcerative colitis, including proctitis, to prevent relapse and disease progression 3.
- Proctocolectomy may be considered as a last resort in cases of refractory proctitis 3.
Role of Antibiotics and Probiotics
- Antibiotics may be used in the management of infectious complications and fistulas in Crohn's disease, but their role in ulcerative colitis is limited 5.
- Probiotics may be effective in pouchitis and may have a role in the initial therapy and maintenance of remission in mild ulcerative colitis, although evidence is limited 5.
Sexually Transmitted Proctitis
- Proctitis can also be caused by sexually transmitted pathogens, including Neisseria gonorrhoeae, Chlamydia trachomatis, and herpes simplex virus 6.
- The diagnosis and management of sexually transmitted proctitis involve a combination of clinical evaluation, laboratory testing, and antimicrobial therapy 6.