What are the treatment options for colitis?

Treatment of Colitis

Treatment of colitis should follow a step-wise approach based on disease extent, severity, and response to therapy, with 5-aminosalicylates as first-line for mild-moderate disease and escalation to biologics or surgery for severe or refractory cases. 1, 2

Classification and Initial Treatment

Mild to Moderate Disease

Proctitis (Limited to Rectum)

• First-line: Mesalazine 1g suppositories once daily
• Alternatives: Mesalazine foam or enemas
• Inadequate response: Add oral mesalazine 2-4g daily

Left-sided Colitis

• First-line: Combination therapy with topical mesalazine plus oral mesalazine 2-4g daily
• Topical formulation should match disease extent

Extensive Colitis

• First-line: Oral mesalazine 2-4g daily plus topical therapy
• Starting at full therapeutic dose (4.8g/day) is more effective than dose escalation 3

Moderate to Severe Disease

• First-line: Oral prednisolone 40mg daily, tapering over 8 weeks
• Continue topical agents as adjunctive therapy
• If no response within 72 hours: Consider second-line therapy or surgical consultation 1

Management of Severe Acute Colitis

Hospitalization Required

• Intravenous steroids: Hydrocortisone 400mg/day or methylprednisolone 60mg/day
• IV fluid and electrolyte replacement (potassium ≥60 mmol/day)
• Subcutaneous heparin for thromboembolism prophylaxis
• Consider empirical IV metronidazole if infection cannot be ruled out 2

Monitoring Response

• Daily assessment of clinical and laboratory parameters
• Critical decision point at 72 hours: If no improvement, initiate second-line therapy or consider surgery 1

Second-line Medical Therapy

• Infliximab (5 mg/kg at 0,2, and 6 weeks, then every 8 weeks) 4
• Cyclosporine or tacrolimus (oral or rectal)
• Consider combination therapy with thiopurines (especially with infliximab) 1

Steroid-Dependent Disease

Treatment options include:

• Thiopurines (azathioprine)
• Anti-TNF agents (preferably combined with thiopurines for infliximab)
• Vedolizumab
• Methotrexate 1

Indications for Surgery

Urgent/Emergency Surgery Required

• Free perforation
• Life-threatening hemorrhage with hemodynamic instability
• Generalized peritonitis
• Toxic megacolon with clinical deterioration or signs of shock
• No improvement after 24-48 hours of treatment for toxic megacolon 1

Elective Surgery Consideration

• Failure to respond to medical therapy including biologics
• Refractory disease despite optimal medical management
• Disease complications or cancer risk 1

Surgical Approach

• Subtotal colectomy with ileostomy is the preferred emergency procedure
• Preserves options for later restorative procedures (IPAA)
• Early surgical consultation is essential in severe cases 1

Special Considerations

Refractory Proctitis and Distal Colitis

Before escalating therapy, evaluate for:

1. Poor adherence to prescribed therapy
2. Inadequate drug delivery to inflamed mucosa
3. Unrecognized complications (proximal constipation, infection)
4. Misdiagnosis (IBS, Crohn's disease, mucosal prolapse, cancer) 1

Pain Management

• Identify and treat underlying cause of pain
• Avoid opioids when possible (risk of dependence, infection, narcotic bowel syndrome)
• Consider tricyclic antidepressants for chronic pain 2

Maintenance Therapy

• Lifelong maintenance therapy generally recommended
• Regular surveillance colonoscopies for dysplasia/cancer screening
• Options based on disease extent and previous response to therapy 2

Important Pitfalls to Avoid

1. Delaying surgery in critically ill patients with toxic megacolon or perforation
2. Inadequate dosing of 5-ASA compounds (start with full therapeutic dose)
3. Prolonged steroid use without appropriate steroid-sparing strategies
4. Failure to recognize infectious causes of colitis (especially C. difficile) 1, 5
5. Not considering multidisciplinary approach with gastroenterology and surgical consultation for severe disease