What is the recommended management for colitis?

From the Guidelines

The management of colitis should prioritize the use of mesalamine (2-3 grams/day) or diazo-bonded 5-ASA for mild-to-moderate cases, with consideration of adding rectal mesalamine for extensive disease, as recommended by the AGA guidelines 1.

Key Recommendations

• For patients with extensive mild-to-moderate ulcerative colitis, standard dose mesalamine or diazo-bonded 5-ASA is recommended over low dose mesalamine, sulfasalazine, or no treatment 1.
• The addition of rectal mesalamine to oral 5-ASA may be considered for patients with extensive mild-to-moderate ulcerative colitis 1.
• For patients with mild-to-moderate ulcerative colitis who do not respond to standard-dose mesalamine or diazo-bonded 5-ASA, high-dose mesalamine (>3gm/d) with rectal mesalamine may be considered for induction of remission 1.

Treatment Approach

The approach to managing colitis involves a step-up strategy, starting with aminosalicylates like mesalamine for mild-to-moderate disease, and progressing to biologic agents or immunomodulators for more severe cases or those unresponsive to first-line treatments 1.

Biologic Agents

For moderate to severe ulcerative colitis, biologic agents such as infliximab, adalimumab, or vedolizumab may be necessary, with the choice of agent depending on patient-specific factors and disease severity 1.

Corticosteroids

Corticosteroids like prednisolone (40 mg daily) may be used for moderate to severe ulcerative colitis, with a tapering regimen over 6-8 weeks 1.

Lifestyle Modifications

Dietary modifications, including avoiding trigger foods and staying hydrated, can help manage symptoms, and regular follow-up with gastroenterologists is essential for monitoring disease activity and preventing complications 1.

From the FDA Drug Label

RENFLEXIS 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. The recommended dose of RENFLEXIS 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 thereafter for the treatment of adult patients with moderately to severely active ulcerative colitis.

The recommended management for colitis (specifically ulcerative colitis) includes:

• Induction regimen: 5 mg/kg of infliximab (RENFLEXIS) at 0,2, and 6 weeks
• Maintenance regimen: 5 mg/kg every 8 weeks This treatment is for adult patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy 2.

From the Research

Management of Colitis

The management of colitis, specifically ulcerative colitis (UC), involves the use of various medications to induce and maintain remission.

• The primary goal of treatment is to reduce inflammation and prevent complications such as colorectal cancer.
• According to 3, aminosalicylates (5-ASA, sulfasalazine, and mesalazine) play a central role in the treatment of UC, with efficacy established for acute treatment of mild to moderate flares and maintenance treatment.

Treatment Options

Several treatment options are available for managing colitis:

• Aminosalicylates, such as mesalamine, are the first-line therapy for inducing and maintaining clinical remission in patients with mild-to-moderate UC 4.
• Topical therapy, including suppositories and enemas, is also effective for treating ulcerative proctitis and proctosigmoiditis 3.
• Oral 5-ASA is safe and well-tolerated for maintenance treatment, and may reduce the risk of colorectal tumors in patients with longstanding UC 3.
• Other treatment options, such as steroids, azathioprine/mercaptopurine, cyclosporine, and infliximab, may be used for patients who are refractory to mesalamine or have more severe disease 4.

Dosing and Formulations

The dosing and formulation of mesalamine can vary:

• Once-daily formulations, such as MMX mesalamine, are available and have been shown to be effective in inducing and maintaining clinical remission in patients with active mild-to-moderate UC 4.
• High-dose 5-ASA therapy may be a valuable option for patients with moderately active disease, and physicians should weigh the pros and cons of this strategy in selected patients 5.
• The use of combination therapy with oral and rectal mesalamine may provide additional efficacy for patients with both distal and extensive colitis 6.

Safety and Efficacy

The safety and efficacy of aminosalicylates have been established:

• Aminosalicylates offer a favorable safety profile compared to immunomodulators and biologics 5.
• The risk of colorectal tumors is increased in patients with longstanding UC, and epidemiological evidence indicates that chronic 5-ASA treatment may reduce this risk 3.
• However, there is insufficient evidence to maintain patients on life-long 5-ASA maintenance treatment for this indication 3.