From the Guidelines
The treatment for lymphocytic colitis typically begins with dietary changes and over-the-counter anti-diarrheal medications, with budesonide considered as first-line therapy for persistent symptoms. According to the American Gastroenterological Association Institute guideline on the medical management of microscopic colitis 1, the goal of medical therapy is to relieve symptoms and improve quality of life while minimizing drug-related adverse effects.
First-Line Treatment
The guideline recommends budesonide, an oral corticosteroid with minimal systemic absorption, as the first-line therapy for inducing remission in microscopic colitis, which includes lymphocytic colitis 1. The recommended dose is 9 mg daily for 6-8 weeks, followed by a gradual taper.
Alternative Treatments
Other medications that may be used include cholestyramine, which binds bile acids, and bismuth subsalicylate 1. For refractory cases, immunosuppressants like azathioprine or 6-mercaptopurine may be considered. In severe cases unresponsive to standard therapies, anti-TNF agents may be an option.
Importance of Diagnosis and Exclusion of Other Causes
It is crucial to diagnose microscopic colitis accurately through colonic biopsy and to consider other causes of chronic diarrhea, such as celiac disease, especially in patients with refractory symptoms 1. Patients should also avoid potential medication triggers like nonsteroidal anti-inflammatory drugs, proton pump inhibitors, and selective serotonin reuptake inhibitors.
Maintenance Therapy
Some patients may require maintenance therapy to prevent relapse, and the choice of medication should be based on the severity of symptoms, response to initial therapy, and the presence of any adverse effects 1. The guideline emphasizes the importance of individualizing treatment to improve quality of life while minimizing adverse effects.
From the Research
Treatment Options for Lymphocytic Colitis
- Dietary changes: Patients with symptomatic lymphocytic colitis should eliminate dietary secretagogues such as caffeine- or lactose-containing food from their diet 2.
- Discontinuation of nonsteroidal anti-inflammatory drugs: When possible, use of nonsteroidal anti-inflammatory drugs should be discontinued 2.
- Low-fat diet: If steatorrhea is documented, a low-fat diet may be helpful 2.
- Binding resins: In the presence of bile salt malabsorption, binding resins such as cholestyramine might be useful 2.
- Nonspecific diarrheal agents: Loperamide hydrochloride, diphenoxylate hydrochloride and atropine, deodorized tincture of opium, or codeine might prove effective in some patients 2.
- Antibacterial agents: Bismuth subsalicylate has been effective in symptom control 2, 3.
- Metronidazole and erythromycin: These antibiotics achieve response rates of 60% 2.
- Sulfasalazine: At the usual dose of 2 to 4 g daily, sulfasalazine demonstrated cessation of diarrhea in 1 to 2 weeks for 50% of patients 2.
- 5-aminosalicylic (5-ASA) compounds: These are preferred for patients with a history of sulfa allergy, and those who experience adverse reactions to sulfasalazine 2.
- Adrenocorticoid medication: Reserved for patients whose conventional treatment with sulfasalazine or 5-ASA has failed 2.
- Budesonide: Effective in treating lymphocytic colitis, with clinical remission achieved in 86% of patients after 6 weeks of treatment 4, 5.
- Mesalazine: With or without cholestyramine, may be effective for the treatment of lymphocytic colitis, but needs to be confirmed by large placebo-controlled studies 4.
- Beclometasone dipropionate: May be effective for the treatment of lymphocytic colitis, but needs to be confirmed by large placebo-controlled studies 4.