From the Guidelines
The management of proctitis should prioritize the use of topical 5-aminosalicylates (5-ASA) such as mesalamine suppositories 1g daily as first-line therapy. This approach is supported by the most recent and highest quality evidence, including the 2019 guidelines from the British Society of Gastroenterology 1 and the 2017 European evidence-based consensus on diagnosis and management of ulcerative colitis 1.
For patients with mild to moderate active ulcerative proctitis, rectal 5-ASA at a dosage of 1 g daily is recommended as first-line therapy to induce symptomatic remission, with a strong recommendation and high-quality evidence 1. The use of mesalamine suppositories is preferred due to their effectiveness in delivering the drug directly to the rectum and being better tolerated compared to other forms of 5-ASA 1.
In cases where patients do not respond to 5-ASA or are intolerant, the addition of topical corticosteroids like hydrocortisone foam or the use of rectal corticosteroid therapy may be considered 1. However, the primary approach should always prioritize 5-ASA therapy due to its efficacy and safety profile.
Supportive care, including sitz baths, stool softeners, and pain management, should be provided to all patients regardless of the underlying cause of proctitis. Dietary modifications, such as avoiding spicy foods, caffeine, and alcohol, can also help reduce symptoms. Treatment success should be monitored through symptom improvement and follow-up examinations, with adjustments to therapy made as needed based on clinical response.
Key points for the management of proctitis include:
- Use of topical 5-ASA (mesalamine suppositories 1g daily) as first-line therapy for inflammatory bowel disease-related proctitis.
- Consideration of topical corticosteroids for patients not responding to 5-ASA or who are intolerant.
- Supportive care and dietary modifications to reduce symptoms.
- Monitoring of treatment success and adjustment of therapy as needed.
From the Research
Proctitis Management Approach
The management of proctitis involves a combination of medical therapies and, in some cases, surgical interventions. The primary goal of treatment is to induce and maintain remission, as well as to prevent disease progression.
Medical Therapies
- Topical aminosalicylates, such as mesalamine suppository, are considered first-line agents for the treatment of ulcerative proctitis due to their effectiveness and rapid action in inducing and maintaining remission 2, 3, 4, 5.
- Oral aminosalicylates, like mesalamine, can also be used, especially in cases where topical treatment is not sufficient or feasible 3, 4.
- Corticosteroids, both topical and systemic, may be used in more severe cases or when there is a lack of response to aminosalicylates 2, 4.
- Immunomodulators or biologic therapy may be considered for patients who are refractory to standard treatments or are steroid-dependent 4.
Treatment Considerations
- The choice of initial therapy may impact the likelihood of therapy escalation and total costs of treatment, with topical mesalamine suppository often being more cost-effective than oral 5-aminosalicylate 3.
- Patient adherence to topical treatments, such as mesalazine suppository, is crucial for achieving and maintaining remission, but adherence can be low 5.
- Empirical therapy may be considered for the management of acute proctitis in specific patient populations, such as homosexual men, but it should be coupled with appropriate diagnostic testing 6.
Surgical Interventions
- Proctocolectomy may be considered as a last resort for patients with ulcerative proctitis who fail to respond to medical therapies or have severe disease complications 4.