From the Guidelines
The most effective treatment for microscopic colitis is budesonide, which should be prescribed at 9mg daily for 6-8 weeks, then tapered off, as it has been shown to induce clinical remission with a low risk of serious adverse events 1. The treatment for microscopic colitis typically begins with lifestyle changes and medications. First-line treatment includes stopping any medications that might be triggering symptoms and avoiding NSAIDs, caffeine, alcohol, and artificial sweeteners.
- Antidiarrheal medications like loperamide (Imodium) can help control symptoms.
- The most effective medication is budesonide (Entocort EC), an oral corticosteroid that targets the intestine with minimal systemic absorption.
- If symptoms return, maintenance therapy at lower doses may be needed, with a strong recommendation for budesonide for maintenance of clinical remission 1. For those who don't respond to budesonide, other options include:
- Cholestyramine (a bile acid binder)
- Bismuth subsalicylate
- Immunosuppressants like azathioprine in severe cases Most patients (70-80%) respond well to these treatments, with many achieving complete remission. The goal is to reduce inflammation in the colon lining, which helps restore normal fluid absorption and reduces diarrhea. In rare, severe cases that don't respond to medication, surgery to remove part of the colon may be considered, but this is uncommon. It's worth noting that the American Gastroenterological Association (AGA) provides a conditional recommendation against the use of probiotics due to the uncertain balance between benefit and harm 1.
From the Research
Treatment Options for Microscopic Colitis
The treatment for microscopic colitis (MC) is multifaceted and depends on the severity of symptoms. Some key points to consider include:
- Elimination of offending medications that may be associated with MC, such as proton pump inhibitors, nonsteroidal anti-inflammatory drugs, selective serotonin reuptake inhibitors, and statins 2, 3
- Use of antidiarrheals like loperamide for mild symptoms 2, 3
- Budesonide is recommended for induction of clinical remission in moderate to severe disease 2, 3, 4, 5
- Low-dose budesonide may be required for maintenance therapy in patients with recurrent symptoms, with close monitoring for potential adverse effects 2, 5
Medication Comparison
Comparative studies have been conducted to evaluate the efficacy of different medications in treating MC. For example:
- A meta-analysis comparing budesonide and mesalamine found that budesonide is associated with increased clinical remission rates and lower incidence of adverse events 4
- Budesonide has been shown to be effective in inducing and maintaining clinical remission, but relapse rates can be high when discontinued 5
Special Considerations
In certain cases, such as MC induced by immune checkpoint inhibitors, budesonide may be an effective treatment option 6. Additionally, immunomodulators and anti-tumor necrosis factor-alpha inhibitors may be considered for refractory disease 3, 5
Treatment Approach
The approach to treatment should be guided by the severity of the patient's symptoms and may involve a stepwise approach, with escalation to more potent therapies as needed 2, 3. Close monitoring and adjustment of treatment are crucial to managing MC effectively.