From the Guidelines
Budesonide is the recommended first-line treatment for microscopic colitis, with a strong recommendation and high quality of evidence, as it has been shown to be effective in inducing clinical remission and improving quality of life 1. The treatment for microscopic colitis typically begins with lifestyle changes and medications. First-line treatment involves eliminating medications that may trigger symptoms (like NSAIDs) and dietary modifications such as reducing caffeine, alcohol, and artificial sweeteners.
- Budesonide (Entocort EC), an oral corticosteroid, is the most effective medication at 9 mg daily for 6-8 weeks, followed by a gradual taper, as recommended by the American Gastroenterological Association (AGA) 1.
- If symptoms return, maintenance therapy at lower doses (3-6 mg daily) may be needed, with a strong recommendation and moderate quality of evidence for the use of budesonide for maintenance of clinical remission 1.
- For those who don't respond to budesonide, other options include cholestyramine (4 g, 1-4 times daily), bismuth subsalicylate (two 262 mg tablets three times daily for 8 weeks), or immunosuppressants like azathioprine in severe cases.
- Most patients respond well to treatment, with budesonide being effective because it works locally in the intestine with minimal systemic absorption, reducing inflammation without significant side effects, as shown in a meta-analysis of 6 randomized clinical trials 1.
- Surgery is rarely needed for microscopic colitis. It is essential to note that the AGA provides a conditional recommendation against the use of probiotics, due to the uncertain balance between benefit and harm, and acknowledges the uncertainty to which the findings from one trial of a specific probiotic formulation can be generalized to the panoply of probiotic products available 1.
From the Research
Treatment Options for Microscopic Colitis
The treatment for microscopic colitis (MC) aims to reduce the number of bowel movements and improve consistency. The following are some treatment options:
- First-line treatment involves counseling the patient about decreasing their risk factors, such as discontinuing smoking and avoiding medications with suspected association, including NSAIDs, proton pump inhibitors, ranitidine, and sertraline 2, 3, 4, 5.
- Loperamide can be used for immediate symptomatic relief as an adjunct to therapy with glucocorticoids 2, 3.
- Budesonide is considered a first-line treatment for MC due to its favorable side effect profile and good efficacy 2, 3, 6, 5.
- Systemic glucocorticoids should be reserved for patients unable to take budesonide 2.
- In glucocorticoid refractory disease, medications that have been tried include cholestyramine, bismuth salicylate, antibiotics, probiotics, aminosalicylates, immunomodulators, and anti-tumor necrosis factor-alpha inhibitors 2, 4.
Comparison of Treatment Options
A comparative meta-analysis of randomized controlled trials found that budesonide is associated with increased clinical remission rates compared to mesalamine, especially after 8 weeks of follow-up 6.
- Budesonide showed significantly higher clinical remission rates than mesalamine (RR=2.29, P=0.003) 6.
- Budesonide also showed a significantly lower incidence of adverse events compared to mesalamine (P=0.002) 6.
Management of Refractory Disease
There is limited data on the management of steroid-dependent microscopic colitis or refractory microscopic colitis 4.
- Immunomodulators seem to have a low response rate (0%-56%) for patients with refractory microscopic colitis 4.
- Anti-tumor necrosis factor (TNF) therapy has shown a response rate of 66%-100% for refractory microscopic colitis 4.
- Anti-TNF and diverting ileostomy may be an option in severe or refractory microscopic colitis 4.