From the Guidelines
Treatment for proctocolitis typically involves mesalamine suppositories (1g daily) or enemas as first-line therapy, with oral mesalamine 2-4g daily added for more extensive disease, as recommended by the AGA guidelines 1. The choice of treatment depends on the cause of proctocolitis, which can be infectious, inflammatory, or due to other factors.
- For infectious proctocolitis, antibiotics such as ciprofloxacin 500mg twice daily for 7-14 days may be used for bacterial causes like Campylobacter or Shigella.
- For Clostridium difficile, oral vancomycin 125mg four times daily for 10-14 days is preferred.
- For inflammatory bowel disease-related proctocolitis, mesalamine suppositories or enemas are first-line, with oral mesalamine added for more extensive disease. Some key points to consider in the treatment of proctocolitis include:
- The use of rectal corticosteroids, such as hydrocortisone or prednisolone, may be considered for patients with inflammatory bowel disease-related proctocolitis who do not respond to mesalamine therapy 1.
- The AGA guidelines recommend using mesalamine suppositories or enemas for patients with proctitis or proctosigmoiditis, with oral mesalamine added for more extensive disease 1.
- Supportive measures, such as hydration, pain management with acetaminophen, and dietary modifications, can help reduce symptoms and improve quality of life. It is essential to note that the treatment of proctocolitis should be individualized based on the patient's specific needs and circumstances, and that regular follow-up is necessary to adjust therapy as needed and ensure resolution of symptoms. The most recent and highest quality study, published in 2019, provides guidance on the management of mild-to-moderate ulcerative colitis, including proctocolitis, and recommends the use of mesalamine suppositories or enemas as first-line therapy 1.
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
- Topical aminosalicylates are effective first-line agents in ulcerative proctitis and distal UC, acting more effectively and rapidly to induce and maintain remission compared to oral counterparts or topical steroids 2, 3.
- Rectally administered 5-ASA and corticosteroid suppositories are effective treatments for most ulcerative proctitis patients 4.
- Mesalazine suppositories are often used as initial therapy in patients with new-onset ulcerative proctitis, while oral 5-ASAs and systemic steroids are commonly used in patients with new-onset ulcerative colitis 5.
- The combination of topical and oral 5-ASA and steroids should be considered for escalation of treatment in patients with proctitis or left-sided ulcerative colitis 3, 4.
Refractory Cases
- Patients with refractory ulcerative proctitis may require systemic corticosteroids, antibiotics, immunomodulators, or surgery 2.
- Immunomodulators or biological response modifier therapy may be necessary for patients refractory to 5-ASAs and corticosteroids 3, 4.
- Proctocolectomy may be considered as a last resort for patients with ongoing signs and symptoms of ulcerative proctitis and left-sided ulcerative colitis despite maximal medical therapy 4.
Alternative Treatments
- Rectal budesonide foam is an effective treatment for mild-to-moderate active distal UC, with a better patient tolerance profile compared to enema formulations 6.
- Alternative medicine can be used complementarily, while experimental approaches are reserved for patients failing conventional medication 3.