What is the treatment for pancolitis (ulcerative colitis involving the entire colon)?

From the Guidelines

Pancolitis treatment should initially involve a combination of medications, including 5-aminosalicylates (5-ASAs) like mesalamine (2.4-4.8g daily) and oral mesalamine ≥ 2.4 g/day, as recommended by the most recent guidelines 1. The treatment of pancolitis typically involves a step-up approach, starting with mild to moderate disease management using 5-ASAs like mesalamine or sulfasalazine.

• For mild to moderately active extensive ulcerative colitis, mesalamine (2.4-4.8g daily) or balsalazide (6.75g daily) are effective first-line therapies 1.
• Corticosteroids such as prednisone (40mg daily, tapered over 8-12 weeks) are used to induce remission in more severe cases 1.
• Immunomodulators like azathioprine (1.5-2.5mg/kg/day) or 6-mercaptopurine (0.75-1.5mg/kg/day) help maintain remission and reduce steroid dependency 1.
• For moderate to severe disease not responding to conventional therapy, biologics including anti-TNF agents (infliximab, adalimumab, golimumab), anti-integrin therapies (vedolizumab), or JAK inhibitors (tofacitinib) may be necessary 1. The goal of treatment is to heal the colonic mucosa, prevent complications, and improve the patient's quality of life.
• Regular monitoring for medication side effects and disease activity is essential for optimal management 1.
• Treatment should be individualized based on disease severity, extent, and patient factors 1.
• Supportive care includes hydration, electrolyte replacement, and nutritional support 1. The most recent guidelines recommend a personalized approach to treatment, taking into account the patient's specific needs and circumstances 1.
• Ozanimod, a small molecule therapy, has been shown to be effective in the treatment of ulcerative colitis, providing an alternative to biologics 1.
• The choice of treatment regimen depends on several factors, including the type, distribution, and disease severity, as well as co-morbidity and patient preferences 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.
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.

Pancolitis treatment with infliximab (IV) involves:

• Reducing signs and symptoms
• Inducing and maintaining clinical remission
• Mucosal healing
• Eliminating corticosteroid use The recommended dose 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 2.

From the Research

Treatment Options for Pancolitis

• Pancolitis is a type of ulcerative colitis that affects the entire colon and can be challenging to treat 3.
• The goals of management are to induce and maintain clinical remission and to screen for complications of the disease 4.
• Treatment options for pancolitis include:
  • Mesalamine, a 5-aminosalicylic acid compound, as first-line therapy to induce and maintain clinical remission in patients with mild-to-moderate UC 4.
  • Steroids, azathioprine/mercaptopurine, cyclosporine, or infliximab for patients who are refractory to mesalamine or have more severe disease 4, 5.
  • Budesonide MMX as an option when treatment with 5-ASA fails, and before using systemic steroids in mild-to-moderate UC 6.
  • Infliximab, adalimumab, vedolizumab, ustekinumab, and tofacitinib as first-line therapy in moderate-to-severe UC 6.

Management of Glucocorticoid-Dependent Pancolitis

• Glucocorticoids are used to treat moderate to severe Crohn's disease, severe ulcerative colitis, and moderate ulcerative colitis failing mesalamine 5.
• However, a substantial minority of patients will later flare with attempts to withdraw therapy, and every effort should be made to switch these patients to a less toxic medication 5.
• Alternatives to glucocorticoids include azathioprine or 6-mercaptopurine, infliximab, methotrexate, and budesonide 5, 6.

Clinical Practice Guidelines

• The American College of Gastroenterology has developed clinical guidelines for the management of adults with UC, which represent the official practice recommendations 7.
• The guidelines indicate the preferred approach to the management of adults with UC and are meant to be broadly applicable 7.
• The update of the PANCCO clinical practice guidelines for the treatment of ulcerative colitis in the adult population provides recommendations for the treatment of UC, including the use of mesalamine, steroids, and biologics 6.