What is the initial treatment for a patient presenting with short segment colitis?

From the Guidelines

The initial treatment for a patient presenting with short segment colitis should involve aminosalicylates, specifically mesalamine, as the first-line therapy. According to the most recent and highest quality study available, 1, the mainstay of therapy for mild-moderate ulcerative colitis, which includes short segment colitis, is the 5-ASA class of medications, including mesalamine.

Key Considerations

• Mesalamine is available in various formulations designed to deliver the active compound to different parts of the small and/or large intestine.
• The therapeutic efficacy and safety of different 5-ASA formulations are similar, allowing for the selection of a specific formulation based on patient needs and preferences.
• For patients with extensive disease, the AGA recommends treating with either standard dose mesalamine or diazo-bonded 5-ASA, with high-dose mesalamine being superior to low-dose for induction of remission.

Treatment Approach

• The recommended initial treatment is an aminosalicylate enema ≥ 1 g/day combined with oral mesalamine ≥ 2.4 g/day, as stated in 1, which is more effective than oral or topical aminosalicylates, or topical steroids alone.
• Once-daily dosing with mesalamine is as effective as divided doses, providing flexibility in treatment regimens.
• Topical mesalamine is more effective than topical steroids, making it a preferable option for patients with left-sided disease.

Additional Therapies

• Oral beclomethasone dipropionate is non-inferior, but not better tolerated, than prednisone after 4 weeks’ treatment, as noted in 1.
• The use of probiotics, such as VSL#3, may have a therapeutic benefit when added to standard therapy to induce remission, although evidence is still emerging 1.
• Fecal microbiota transplantation shows promise in inducing remission in active UC, but more studies are needed to define the best protocol and ensure safety 1.

From the Research

Initial Treatment for Short Segment Colitis

The initial treatment for a patient presenting with short segment colitis typically involves the use of aminosalicylates, such as mesalamine, which are considered first-line therapy for inducing and maintaining clinical remission in patients with mild-to-moderate ulcerative colitis 2.

• Mesalamine: This medication can be administered orally or topically, and its effectiveness has been demonstrated in various studies 3, 2, 4.
• Topical Mesalamine: Topical mesalamine, such as suppositories or enemas, is effective for patients with proctitis or proctosigmoiditis, and can be used in combination with oral mesalamine for more extensive disease 3, 4.
• Oral Mesalamine: Oral mesalamine is effective for inducing and maintaining remission in patients with mild-to-moderate ulcerative colitis, and higher doses (≥3.3 g/day) may be more efficacious than lower doses 4.

Alternative Treatments

For patients who are refractory to mesalamine or have more severe disease, alternative treatments such as corticosteroids, azathioprine/mercaptopurine, cyclosporine, or infliximab may be used 2, 5, 6.

• Corticosteroids: Corticosteroids are effective for inducing remission in patients with moderate to severe ulcerative colitis, but their long-term use is limited due to potential side effects 3, 5.
• Immunomodulators: Immunomodulators such as azathioprine and mercaptopurine are effective for maintaining remission in patients with chronically active or corticosteroid-dependent disease 3, 5.