What is the treatment for acute colitis?

From the Guidelines

Treatment for acute colitis should prioritize intravenous corticosteroids, such as methylprednisolone 60 mg daily, as the initial management, with a potential switch to infliximab or ciclosporin if there's insufficient response, as evidenced by the most recent and highest quality study 1.

Initial Management

The initial management of acute colitis involves a combination of medications and supportive care.

• Intravenous corticosteroids, such as methylprednisolone 60 mg daily, are the standard initial treatment for acute severe ulcerative colitis, with an overall response rate of 67% 1.
• Patients should receive adequate intravenous fluids and low-molecular-weight heparin for thromboprophylaxis.
• Electrolyte abnormalities and anemia should be corrected if needed.

Supportive Care

Supportive care is crucial in the management of acute colitis.

• Nutritional support, preferably enteral nutrition, should be provided if the patient is malnourished, as it is associated with fewer complications than parenteral nutrition 1.
• Patients should maintain hydration and follow a low-residue diet, avoiding spicy foods, caffeine, and alcohol.
• Pain management with acetaminophen is preferred over NSAIDs, which can worsen symptoms.

Steroid-Resistant Cases

For patients who do not respond to intravenous corticosteroids, alternative treatments should be considered.

• Infliximab (5 mg/kg) or ciclosporin (2 mg/kg/day) may be used as rescue therapy, with comparable outcomes 1.
• Surgery may be necessary in cases of severe disease or insufficient response to medical therapy.

Antibiotics and Other Medications

Antibiotics should not be routinely administered in the treatment of acute colitis.

• Controlled trials have shown no consistent benefit of antibiotics, such as metronidazole, tobramycin, ciprofloxacin, or vancomycin, in addition to conventional therapy 1.
• Immunosuppressants, such as azathioprine, may be used in steroid-resistant cases or as maintenance therapy.

From the FDA Drug Label

Mesalamine delayed-release tablets are an aminosalicylate indicated for the: (1) induction and maintenance of remission in adult patients with mildly to moderately active ulcerative colitis. The treatment for acute colitis is not directly addressed in the provided drug label, as it specifically mentions ulcerative colitis. However, mesalamine is used for the treatment of ulcerative colitis, which may be relevant in some cases of colitis. Key points:

• Mesalamine is indicated for ulcerative colitis, not specifically acute colitis.
• The label does not provide information on the treatment of acute colitis. 2

From the Research

Treatment Options for Acute Colitis

• Corticosteroids are the mainstay of treatment for hospitalized patients with acute severe ulcerative colitis (ASUC) 3, 4.
• The addition of mesalamine to corticosteroids during hospitalization does not appear to provide significant benefits over corticosteroids alone in the treatment of ASUC 3.
• For patients who fail steroid therapy, rescue medical therapy with either infliximab or cyclosporine may be necessary 4.
• Emergency colectomy is required in a timely manner for patients who fail rescue medical therapy to minimize the risk of adverse post-operative outcomes 4.

Role of Mesalamine in Treatment

• 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 ulcerative colitis 5, 6, 7.
• Mesalamine is effective in inducing and maintaining clinical remission in patients with active mild-to-moderate UC, with doses of more than 2.4 g/d achieving higher rates of clinical and endoscopic remission 5, 7.
• Mesalamine is considered safe in pregnancy, excluding formulations with dibutyl phthalate 7.

Management Approaches

• Optimal management of ASUC includes admission to a specialist gastrointestinal unit and joint management with colorectal surgeons 4.
• Patients need to be screened for concomitant infections and thromboprophylaxis should be administered to mitigate against the elevated risk of thromboembolism 4.
• The use of once-daily formulations of mesalamine has led to interest in whether simplified pill regimens can improve patient adherence to mesalamine therapy 5.