From the Guidelines
The most effective management approach for lymphocytic colitis is treatment with budesonide for the induction of clinical remission, as recommended by the American Gastroenterological Association (AGA) 1.
Key Recommendations
- Budesonide is the preferred treatment over no treatment, mesalamine, or other alternatives for inducing clinical remission in patients with symptomatic microscopic colitis, including lymphocytic colitis 1.
- The AGA suggests treatment with mesalamine, bismuth salicylate, or prednisolone as alternatives when budesonide therapy is not feasible, although the quality of evidence for these recommendations is lower 1.
Treatment Approach
- Budesonide should be used at a dose of 9 mg daily for 6-8 weeks, followed by a taper, to effectively reduce inflammation with minimal systemic side effects.
- For patients who experience recurrence of symptoms after discontinuation of induction therapy, budesonide is recommended for maintenance of clinical remission, with a dose of 6 mg daily over 6 months, which has been shown to result in a 66% lower relative risk of clinical relapse 1.
Important Considerations
- Maintenance therapy with budesonide should only be offered to patients who have had a clinical relapse after cessation of induction therapy, and the dose should be tapered to the lowest effective dose to minimize the risk of bone loss and other side effects.
- Regular follow-up is essential to monitor response and adjust therapy as needed, with consideration of osteoporosis prevention and screening in patients requiring maintenance therapy.
From the Research
Management Approaches for Lymphocytic Colitis
The management of lymphocytic colitis involves various approaches, including dietary changes, medication, and surgery in severe cases.
- Dietary changes: Patients with symptomatic collagenous-lymphocytic colitis should eliminate dietary secretagogues such as caffeine- or lactose-containing food from their diet 2.
- Medication:
- Nonspecific diarrheal agents such as loperamide hydrochloride, diphenoxylate hydrochloride and atropine, deodorized tincture of opium, or codeine might prove effective in some patients 2.
- Antibacterial agents such as bismuth subsalicylate have been effective in symptom control 2, 3.
- Metronidazole and erythromycin achieve response rates of 60% 2.
- Sulfasalazine, at the usual dose of 2 to 4 g daily, used in collagenous-lymphocytic colitis, demonstrated cessation of diarrhea in 1 to 2 weeks for 50% of patients 2.
- Budesonide may be effective for the treatment of active lymphocytic colitis, with clinical response noted in 88% of budesonide patients compared to 38% of placebo patients 3, 4.
- Mesalazine with or without cholestyramine and beclometasone dipropionate may be effective for the treatment of lymphocytic colitis, however this needs to be confirmed by large placebo-controlled studies 3.
- Surgery: Surgical management is reserved for those patients with disease refractory to medical therapy, with colectomy with ileostomy resulting in clinical and histologic resolution in small case series 2.
Treatment Efficacy and Safety
The efficacy and safety of treatments for lymphocytic colitis have been evaluated in several studies.
- Budesonide has been shown to be effective and safe for induction of clinical and histologic remission in patients with lymphocytic colitis, compared with placebo 4.
- Mesalazine was not significantly better than placebo in inducing clinical remission 4.
- The incidence of adverse events was 47.4% in the budesonide group, 68.4% in the mesalazine group, and 42.1% in the placebo group 4.
Long-term Follow-up
Long-term follow-up studies have shown that most patients with lymphocytic and collagenous colitis improve with therapy such as 5-ASA preparations or steroids, and generally do not require maintenance medications 5.