From the Guidelines
Management of lymphocytic colitis should prioritize controlling symptoms and improving quality of life, with first-line treatment involving dietary modifications and medications such as loperamide and budesonide. The condition typically presents with chronic, watery, non-bloody diarrhea, abdominal pain, fatigue, and weight loss. According to the most recent guidelines 1, the best practice advice for managing immune checkpoint inhibitor colitis includes excluding infectious causes of diarrhea, using early stool testing for inflammatory markers, and considering endoscopic confirmation of the diagnosis and severity of colitis. Medications such as loperamide (2-4 mg as needed, up to 16 mg daily) can be used for symptom control, while budesonide, an oral corticosteroid with minimal systemic absorption, is highly effective at 9 mg daily for 6-8 weeks, followed by a gradual taper 1. For patients who don't respond to budesonide, alternatives include cholestyramine (4 g, 1-4 times daily), bismuth subsalicylate (eight 262-mg tablets daily in divided doses for 8 weeks), or mesalamine (2.4-4.8 g daily) 1. In cases of refractory colitis, immunosuppressants like azathioprine (1.5-2.5 mg/kg/day) or biologics may be considered, with infliximab and vedolizumab being reasonable options for treatment of glucocorticoid refractory colitis 1. Regular follow-up is essential to monitor treatment response and adjust therapy as needed, with patients being educated about potential triggers and the importance of medication adherence. Some key considerations in managing lymphocytic colitis include:
- Excluding infectious causes of diarrhea before treatment
- Using early stool testing for inflammatory markers to stratify high-risk patients
- Considering endoscopic confirmation of the diagnosis and severity of colitis
- Using medications such as loperamide and budesonide for symptom control
- Considering alternatives such as cholestyramine, bismuth subsalicylate, or mesalamine for patients who don't respond to budesonide
- Using immunosuppressants like azathioprine or biologics for refractory cases. Overall, the goal of management is to control symptoms, improve quality of life, and prevent relapses, with the most recent guidelines providing a framework for best practices in managing lymphocytic colitis 1.
From the Research
Management Considerations for Lymphocytic Colitis
- The management of lymphocytic colitis involves eliminating dietary secretagogues such as caffeine- or lactose-containing food from the diet, and discontinuing the use of nonsteroidal anti-inflammatory drugs when possible 2.
- A low-fat diet may be helpful if steatorrhea is documented, and binding resins such as cholestyramine may be useful in the presence of bile salt malabsorption 2.
- Nonspecific diarrheal agents such as loperamide hydrochloride, diphenoxylate hydrochloride, and atropine, deodorized tincture of opium, or codeine may be effective in some patients 2.
Treatment Options
- Antibacterial agents such as bismuth subsalicylate have been effective in symptom control, with response rates of 60% for metronidazole and erythromycin 2.
- Sulfasalazine, at a dose of 2 to 4 g daily, has demonstrated cessation of diarrhea in 1 to 2 weeks for 50% of patients, while other 5-aminosalicylic (5-ASA) compounds are preferred for patients with a history of sulfa allergy or adverse reactions to sulfasalazine 2.
- Budesonide has been shown to be effective in treating lymphocytic colitis, with clinical remission rates of 86% at 6 weeks, and histologic remission rates of 73% 3, 4.
- Mesalazine has not been shown to be significantly better than placebo in inducing clinical and histologic remission in patients with lymphocytic colitis 4.
Symptoms and Diagnosis
- Lymphocytic colitis is characterized by chronic, nonbloody diarrhea, and diagnosis is based on pathological examination of colonic biopsies 5.
- Patients with lymphocytic colitis may experience watery diarrhea, and the disease can be accompanied by other symptoms such as abdominal pain and weight loss.
- If there is no abatement of symptoms, other etiologies of diarrhea such as thyroid dysfunction, celiac disease, or bacterial overgrowth should be ruled out 2.
Surgical Management
- Surgical management is reserved for patients with disease refractory to medical therapy, and colectomy with ileostomy has resulted in clinical and histologic resolution in small case series 2.