What are the guidelines for the diagnosis and management of colitis (inflammatory bowel disease)?

From the Guidelines

Colitis management should prioritize the use of 5-aminosalicylates, such as mesalamine, as first-line therapy for mild to moderate ulcerative colitis, with a recommended dose of 2-3 grams per day, as suggested by the AGA Clinical Guidelines Committee 1.

Diagnosis and Initial Evaluation

Colitis management begins with accurate diagnosis through a combination of:

• Clinical evaluation
• Laboratory tests, including stool studies to rule out infectious causes and blood tests to assess inflammation markers like C-reactive protein and erythrocyte sedimentation rate
• Endoscopy, such as colonoscopy, with biopsies to determine the type and extent of colitis
• Imaging studies, as needed

Treatment Approach

Treatment depends on the specific type and severity of colitis. For mild to moderate ulcerative colitis, the following approaches are recommended:

• First-line therapy: 5-aminosalicylates, such as mesalamine (2-3 grams per day) or diazo-bonded 5-ASA, as recommended by the AGA Clinical Guidelines Committee 1
• For patients with suboptimal response to standard-dose mesalamine or diazo-bonded 5-ASA, or with moderate disease activity, high-dose mesalamine (>3gm/d) with rectal mesalamine may be considered, as suggested by the AGA Clinical Guidelines Committee 1
• For patients with left-sided mild-moderate ulcerative proctosigmoiditis or proctitis, mesalamine enemas (or suppositories) are recommended, as suggested by the AGA Clinical Guidelines Committee 1
• For patients with mild-moderate ulcerative proctitis, mesalamine suppositories are recommended, as suggested by the AGA Clinical Guidelines Committee 1

Additional Considerations

• Corticosteroids, such as prednisone, may be used for short-term management of more severe cases or those not responding to initial therapy, as suggested by the AGA Clinical Guidelines Committee 1
• Immunomodulators, such as azathioprine or 6-mercaptopurine, may be considered for maintenance therapy, as suggested by the AGA Clinical Guidelines Committee 1
• Biological agents, including anti-TNF medications, anti-integrin therapies, or JAK inhibitors, may be necessary for moderate to severe disease, as suggested by the AGA Clinical Guidelines Committee 1
• Infectious colitis requires targeted antimicrobial therapy based on the identified pathogen, as suggested by the AGA Clinical Guidelines Committee 1
• Supportive care, including hydration, electrolyte replacement, and dietary modifications, is essential, as suggested by the AGA Clinical Guidelines Committee 1
• Regular follow-up is necessary to monitor disease activity, medication effectiveness, and potential complications, as suggested by the AGA Clinical Guidelines Committee 1

From the FDA Drug Label

INDICATIONS AND USAGE RENFLEXIS is a tumor necrosis factor (TNF) blocker indicated for: 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)

The management and diagnosis of colitis (specifically ulcerative colitis) may involve the use of infliximab (a TNF blocker) for:

• Reducing signs and symptoms
• Inducing and maintaining clinical remission
• Achieving mucosal healing
• Eliminating corticosteroid use in adult patients with moderately to severely active disease who have had an inadequate response to conventional therapy 2.
• 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 2. Key points:
• Infliximab is used for moderately to severely active ulcerative colitis
• It is used in adult and pediatric patients 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 achieve mucosal healing 2 2.

From the Research

Diagnosis of Colitis

• The diagnosis of colitis is based on a combination of clinical presentation, endoscopic findings, histology, and the absence of alternative diagnoses 3.
• Ileocolonoscopy with biopsy is the only way to make a definitive diagnosis of ulcerative colitis (UC) 3.
• Histopathology is the definitive tool in diagnosing UC, assessing the disease severity and identifying intraepithelial neoplasia (dysplasia) or cancer 3.
• Abdominal computed tomographic (CT) scanning is the preferred initial radiographic imaging study in UC patients with acute abdominal symptoms 3.

Management of Ulcerative Colitis

• The goals of treatment in UC are to improve quality of life, achieve steroid-free remission, and minimize the risk of cancer 3.
• The choice of treatment depends on disease extent, severity, and the course of the disease 3.
• For proctitis, topical 5-aminosalicylic acid (5-ASA) drugs are used as the first-line agents 3.
• UC patients with more extensive or severe disease should be treated with a combination of oral and topical 5-ASA drugs +/- corticosteroids to induce remission 3.
• 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 UC 4, 5.
• MMX mesalamine is an oral, once-daily tablet formulation of mesalamine used for the treatment of UC 4.

Treatment Approaches

• Patients with severe UC need to be hospitalized for treatment, and options include intravenous steroids and if refractory, calcineurin inhibitors or tumor necrosis factor-α antibodies 3.
• Indications for emergency surgery include refractory toxic megacolon, colonic perforation, or severe colorectal bleeding 3.
• Azathioprine and mercaptopurine are effective in reducing either the need for corticosteroids or clinical relapses, and are effective for long-term maintenance remission 6.
• Cyclosporin may be useful in inducing remission in patients with acutely severe disease who do not achieve remission with an intensive intravenous regimen 6.

Infectious Colitis

• The management of acute colitis in adults depends upon the establishment of the cause 7.
• Most forms of infectious colitis are treatable with antimicrobials 7.
• Multiplex polymerase chain reaction (PCR) followed by guided culture on PCR-positive pathogens can often confirm active infection while standard culture methods provide isolates for antibiotic susceptibility testing 7.