What is the diagnosis and treatment for colitis (inflammation of the colon)?

From the Guidelines

Colitis should be diagnosed and treated based on its specific type, with ulcerative colitis typically managed with 5-aminosalicylates, corticosteroids, and immunomodulators or biologics as needed, while infectious colitis, ischemic colitis, and microscopic colitis require distinct approaches. The diagnosis of colitis involves considering differentials such as infection, Crohn's disease, and irritable bowel syndrome, and may require sigmoidoscopy or colonoscopy to exclude more extensive disease 1. For moderate to severe ulcerative colitis, treatment with oral corticosteroids such as prednisolone 40 mg daily, tapered over 6-8 weeks, is recommended 1. In cases of acute severe colitis, intravenous steroids or ciclosporin may be used, with supportive care including fluids, electrolyte correction, and thromboprophylaxis 1. For immunosuppressant refractory cases, testing for fecal lactoferrin and calprotectin, as well as screening labs and imaging, may be considered 1. Best practice advice for immune checkpoint inhibitor colitis includes excluding infectious causes, using stool testing for inflammatory markers, and considering endoscopic confirmation of diagnosis and severity 1. A management algorithm for ICI colitis involves supportive care, withholding ICI therapy, and using oral or IV corticosteroids, with consideration of infliximab or vedolizumab for refractory cases 1. Key points to consider in the diagnosis and treatment of colitis include:

• Staying hydrated and avoiding trigger foods
• Seeking immediate medical attention for severe symptoms
• Using a step-up approach to treatment, with increasing intensity of therapy as needed
• Considering the potential for complications such as bowel perforation or abscess
• Monitoring for response to treatment and adjusting the treatment plan as needed.

From the FDA Drug Label

Ulcerative Colitis: • reducing signs and symptoms, inducing and maintaining clinical remission and mucosal healing, and eliminating corticosteroid use in adult patients with moderately to severely active disease who have had an inadequate response to conventional therapy. (1. 3) Pediatric Ulcerative Colitis: • reducing signs and symptoms and inducing and maintaining clinical remission in pediatric patients with moderately to severely active disease who have had an inadequate response to conventional therapy. (1. 4) The diagnosis of colitis is not explicitly stated in the label, but the treatment for ulcerative colitis with infliximab (IV) is:

• Adults: 5 mg/kg at 0,2 and 6 weeks, then every 8 weeks 2
• Pediatrics: 5 mg/kg at 0,2 and 6 weeks, then every 8 weeks 2 Key points:
• Infliximab is used to reduce signs and symptoms and induce and maintain clinical remission in patients with moderately to severely active ulcerative colitis.
• The treatment is for patients who have had an inadequate response to conventional therapy.

From the Research

Diagnosis and Treatment of Colitis

The diagnosis and treatment of colitis, specifically ulcerative colitis (UC), involve a multi-faceted approach.

• The treatment strategies must take into account the current clinical presentation, extent, and severity of disease activity, as well as long-term treatment options 3.
• For mild to moderate UC, 5-aminosalicylic acid (mesalazine) is considered first-line therapy, with doses of at least 4 g/day recommended for faster and higher remission rates 4, 5.
• Combining oral and rectal formulations of 5-aminosalicylic acid can lead to faster and higher remission rates, especially for patients with extensive disease 4.
• For patients with mild-moderate UC who do not improve within 2 weeks of high-dose 5-aminosalicylic acid, treatment should be augmented by oral steroids 4.
• Moderate-to-severe UC generally requires oral or intravenous corticosteroids in the short-term, with consideration of long-term management options such as biologic agents or thiopurines 3.
• Patients with severe or fulminant UC who are recalcitrant to medical therapy or develop disease complications may require colectomy, and early surgical referral is crucial 3.

Treatment Options

• Mesalamine is a 5-aminosalicylic acid compound that is the first-line therapy to induce and maintain clinical remission in patients with mild-to-moderate UC 6.
• MMX mesalamine, a once-daily tablet formulation of mesalamine, has been shown to effectively induce and maintain clinical remission in patients with active mild-to-moderate UC 6.
• Newer advanced therapies, including anti-TNF, anti-integrin, and anti-IL12/23 agents, as well as JAK inhibitors and sphingosine1-phosphate receptor modulators, are effective in treating UC, but choosing among treatments can be complicated 7.
• The choice of treatment should be based on effectiveness, safety, specific disease features, patient factors, and patient preference 7.