What is the recommended treatment for lymphocytic microscopic colitis?

From the Guidelines

The recommended treatment for lymphocytic microscopic colitis is budesonide, an oral corticosteroid, at a dose of 9 mg daily for 6-8 weeks, followed by a gradual taper, as it has shown effectiveness in inducing remission and improving quality of life 1.

Treatment Overview

The treatment of lymphocytic microscopic colitis aims to relieve symptoms and improve quality of life while minimizing drug-related adverse effects.

• Budesonide is the first-line treatment for inducing clinical remission in patients with symptomatic microscopic colitis, with a strong recommendation and high quality of evidence 1.
• The use of budesonide has been shown to be more effective than mesalamine for the induction of clinical remission, with a strong recommendation and high quality of evidence 1.
• For patients who have had a clinical relapse after cessation of induction therapy, maintenance therapy with budesonide may be considered, with a strong recommendation and moderate quality of evidence 1.

Symptom Management

For milder cases, symptom management may include:

• Over-the-counter antidiarrheal medications like loperamide (2-4 mg as needed, not exceeding 16 mg daily) or bismuth subsalicylate (two tablets three times daily).
• Dietary modifications, including avoiding caffeine, alcohol, dairy products (if lactose intolerant), and artificial sweeteners, particularly those containing sorbitol or mannitol.

Second-Line Treatments

If budesonide is ineffective or not tolerated, second-line treatments may include:

• Cholestyramine (4 g once to three times daily), which binds bile acids that may contribute to diarrhea.
• Immunossuppressants like azathioprine (50-150 mg daily) for refractory cases.

Maintenance Therapy

Maintenance therapy with budesonide may be considered for patients who have had a clinical relapse after cessation of induction therapy, with a strong recommendation and moderate quality of evidence 1.

• The dose of budesonide for maintenance therapy may be tapered to the lowest effective dose, and cessation of maintenance therapy can be considered after 6 to 12 months 1.

From the Research

Treatment Options for Lymphocytic Colitis

• The approach to treatment is similar for both lymphocytic colitis and collagenous colitis and should be guided by the severity of the patient's symptoms 2.
• Offending medications highly associated with lymphocytic colitis, such as proton pump inhibitors, nonsteroidal anti-inflammatory drugs, selective serotonin reuptake inhibitors, and statins, should be eliminated as clinically possible 2, 3.
• For patients with mild symptoms, antidiarrheals such as loperamide are the initial choice 2.
• For moderate to severe disease, budesonide is recommended for induction of clinical remission 2, 4, 5, 6.
• Budesonide has been shown to be effective in inducing clinical and histological response in patients with lymphocytic colitis, with a significant improvement in clinical remission rates compared to mesalamine 4, 5, 6.
• Low-dose budesonide may be required for maintenance therapy in patients with recurrent symptoms, with close monitoring for potential adverse effects 2.
• Other treatment options, such as mesalamine with or without cholestyramine, and beclometasone dipropionate, may be effective, but the evidence is weaker and more studies are needed to confirm their efficacy 4, 6.
• In rare cases, immunomodulators may be required for patients with refractory lymphocytic colitis 5.

Safety and Efficacy of Treatment Options

• Budesonide has been shown to be well-tolerated and effective in inducing and maintaining clinical and histological responses in patients with lymphocytic colitis 4, 5, 6.
• The incidence of adverse events was significantly lower in patients treated with budesonide compared to mesalamine 5.
• Common adverse events reported with budesonide include nausea, vomiting, neck pain, abdominal pain, hyperhidrosis, and headache 4.
• The safety and efficacy of other treatment options, such as mesalamine and beclometasone dipropionate, are less well-established and require further study 4, 6.