What are the treatment options for colitis?

From the Guidelines

Treatment of colitis should prioritize the use of aminosalicylates, such as mesalamine, and corticosteroids, like prednisolone, as first-line therapies, with ozanimod being a promising novel oral small molecule therapy for moderately to severely active ulcerative colitis. When considering treatment options for colitis, it is essential to differentiate between the type and severity of the condition. For mild to moderate ulcerative colitis, first-line treatments typically include anti-inflammatory medications such as 5-aminosalicylates (mesalamine, sulfasalazine) at doses of 2-4g daily 1.

Key Treatment Considerations

• Corticosteroids like prednisone (40-60mg daily, tapered over 8-12 weeks) may be used for moderate to severe flares to quickly reduce inflammation 1.
• For maintenance therapy, immunomodulators such as azathioprine (2-3mg/kg/day) or 6-mercaptopurine (1-1.5mg/kg/day) can help prevent relapses.
• In more severe or resistant cases, biologic therapies like infliximab (5mg/kg IV at weeks 0,2, and 6, then every 8 weeks), adalimumab, or vedolizumab may be necessary.
• Ozanimod, an oral small molecule therapy, has shown promise in the treatment of moderately to severely active ulcerative colitis, offering a safer and more effective or convenient treatment option 1.

Additional Therapies and Considerations

• Dietary modifications, including low-residue diets during flares and identifying trigger foods, can complement medical therapy.
• In cases unresponsive to medication or with complications like perforation or toxic megacolon, surgical intervention may be required, potentially including colectomy.
• Treatment should be individualized based on disease location, severity, and patient factors, with regular monitoring of symptoms and medication side effects.
• The use of probiotics, such as VSL#3, and faecal transplantation (FT) may also be considered as adjunctive therapies, although more research is needed to fully understand their efficacy and safety 1.

From the FDA Drug Label

RENFLEXIS is 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. 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.

The treatment options for colitis include infliximab (IV), which is indicated for:

• Reducing signs and symptoms, inducing and maintaining clinical remission and mucosal healing, and eliminating corticosteroid use in adult patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy.
• Reducing signs and symptoms and inducing and maintaining clinical remission in pediatric patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy. The recommended dose of infliximab (IV) for ulcerative colitis is 5 mg/kg given as an intravenous induction regimen at 0,2 and 6 weeks followed by a maintenance regimen of 5 mg/kg every 8 weeks 2, 2, 2.

From the Research

Treatment Options for Colitis

The treatment options for colitis, specifically ulcerative colitis (UC), can be categorized based on the severity of the disease.

• For mild to moderate UC, 5-aminosalicylic acid (5-ASA) compounds, such as mesalamine, are the first-line therapy to induce and maintain clinical remission 3, 4, 5, 6.
• Mesalamine has been shown to be effective in inducing and maintaining clinical remission in patients with active mild-to-moderate UC, with response rates between 40%-70% and remission rates of 15%-20% 3.
• The optimal dosage of mesalamine for mild-moderate distal active disease is 4.8 g/day, and for maintenance therapy, it is 2.4 g/day 3.
• For patients with moderately active ulcerative colitis, mesalamine has been shown to be safe in short-term use with a dose-response efficacy without dose-related toxicity 3.
• In the setting of left-sided distal colitis (proctitis), topical (rectal) formulations of mesalamine have been found to be superior to oral aminosalicylates at inducing remission 3.
• For patients who are refractory to mesalamine or have more severe disease, other treatment options include steroids, azathioprine/mercaptopurine, cyclosporine, or infliximab to induce and/or maintain remission 4, 7.
• The use of once-daily formulations of mesalamine, such as MMX mesalamine, has led to improved patient adherence to mesalamine therapy 4.
• Moderate to severe UC may require oral corticosteroids for induction of remission as a bridge to medications that sustain remission, such as biologic monoclonal antibodies against tumor necrosis factor, α4β7 integrins, and interleukin 12 and 23, and oral small molecules that inhibit janus kinase or modulate sphingosine-1-phosphate 5.

Disease Management

• The goals of management are to induce and maintain clinical remission and to screen for complications of the disease 4, 7.
• Risk stratification by disease location and disease activity can guide management of UC 5.
• Patients with UC require monitoring of symptoms and biomarkers of inflammation, and require colonoscopy at 8 years from diagnosis for surveillance of dysplasia 5.
• The Mayo scoring system is a commonly used index to assess disease severity and monitor patients during therapy 7.
• The choice of treatment depends on disease extent, severity, and the course of the disease 7.