What is the treatment for colitis?

From the Guidelines

The treatment for colitis, specifically ulcerative colitis, should start with intravenous steroids, such as methylprednisolone 60 mg every 24 hours or hydrocortisone 100 mg four times daily, for severe active cases, as recommended by the most recent and highest quality evidence 1. When considering the management of colitis, it's crucial to differentiate between types and severity levels. For mild to moderate cases, anti-inflammatory medications like aminosalicylates (mesalamine, sulfasalazine) at doses of 2-4g daily can be effective. However, for moderate to severe flares, corticosteroids such as prednisolone 40 mg daily, tapering over 6-8 weeks, are recommended, based on strong evidence and high-quality research 1. In cases of severe or refractory colitis, biologics like infliximab or adalimumab may be necessary, alongside supportive care including hydration, electrolyte replacement, and sometimes antibiotics for infections. Dietary modifications, such as low-residue diets during flares, can also help manage symptoms. For microscopic colitis, budesonide is recommended as first-line therapy for the induction of clinical remission, given its favorable risk/benefit profile and convenience of once-daily dosing 1. In patients where budesonide is not feasible, prednisolone may be considered, although the evidence for its use is of lower quality 1. Recent guidelines and studies, including those from 2023, highlight the emergence of new treatments such as ozanimod for ulcerative colitis, offering oral administration and potentially rapid onset, although they also come with their own set of considerations and risks 1. Key points to consider in the treatment of colitis include:

• Differentiating between types of colitis (ulcerative, microscopic) and severity levels
• Using anti-inflammatory medications for mild to moderate cases
• Corticosteroids for moderate to severe flares
• Biologics for severe or refractory cases
• Supportive care and dietary modifications to manage symptoms
• Considering new and emerging treatments, weighing their benefits and risks.

From the FDA Drug Label

1 INDICATIONS AND USAGE PENTASA is indicated for the induction of remission and for the treatment of mildly to moderately active ulcerative colitis in adult patients.

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.

The treatment for colitis includes:

• Mesalamine (PO) for mildly to moderately active ulcerative colitis in adult patients 2
• Infliximab (IV) for moderately to severely active ulcerative colitis in adult patients who have had an inadequate response to conventional therapy 3

From the Research

Treatment Options for Colitis

• The treatment for colitis, specifically ulcerative colitis, typically involves the use of medications such as sulfasalazine, mesalamine, and corticosteroids 4, 5, 6.
• Mesalamine has been shown to be effective in treating refractory cases of distal ulcerative colitis, proctitis, and proctosigmoiditis 4.
• Sulfasalazine has been used for many years in the management of ulcerative colitis, but it can cause intolerable adverse effects in some patients 4, 7.
• Other treatment options include immunosuppressive agents, such as azathioprine and mercaptopurine, which can be effective in reducing the need for corticosteroids or clinical relapses 6.
• Topical corticosteroids, such as budesonide and fluticasone, can also be used to treat active ulcerative colitis 6.

Medication Dosage and Efficacy

• The dosage of mesalamine can vary, but studies have shown that doses above 1.5 g may not be necessary for induction therapy, and doses above 1.5 g may not be necessary for maintenance therapy 5.
• Sulfasalazine has been shown to be effective at doses of 4.5 g/day, but it can cause more frequent side effects than other medications 5, 8.
• Mesalamine has been shown to reduce the risk of colorectal cancer in patients with ulcerative colitis, especially at doses of 1.2 g or higher 5.

Alternative Treatment Options

• Metronidazole has been studied as a potential treatment for ulcerative colitis, but it has been found to be ineffective in treating acute attacks of the disease 8.
• Other alternative treatments, such as 5-lipoxygenase inhibitors, topical use of short chain fatty acids, and nicotine, have been studied, but more research is needed to determine their efficacy 6.