What is the recommended treatment for microscopic colitis?

Treatment for Microscopic Colitis

Budesonide is the first-line treatment for symptomatic microscopic colitis, with strong evidence supporting its effectiveness for both induction and maintenance therapy. 1

First-Line Treatment

Induction Therapy

• Budesonide 9 mg daily for 8 weeks
  • Strong recommendation based on moderate quality evidence 1
  • More than doubles the likelihood of achieving clinical remission compared to no treatment (RR 2.52) 1
  • Significantly reduces frequency of soft/watery stools 2
  • Improves health-related quality of life 2
  • Low risk of serious adverse events 1

Maintenance Therapy

• For patients who experience symptom recurrence after induction therapy:
  • Budesonide 6 mg daily for 6 months 1
  • Can be tapered to lowest effective dose 1
  • Reduces risk of clinical relapse by 66% (RR 0.34) 1
  • Consider discontinuation after 6-12 months 1
  • Monitor for bone loss with prolonged use 1

Alternative Treatments (when budesonide is not feasible)

In order of preference:

1. Mesalamine 3 g daily 1

   • Conditional recommendation, moderate quality evidence
   • Less effective than budesonide (RR 1.7 vs 2.29 for clinical remission at 8 weeks) 3

2. Bismuth salicylate

   • Conditional recommendation, low quality evidence 1
   • 8-9 tablets divided 3 times daily 1
   • Consider pill burden in elderly patients 1

3. Prednisolone/prednisone

   • Conditional recommendation, very low quality evidence 1
   • Consider when cost of budesonide is prohibitive 1
   • Less evidence supporting efficacy compared to budesonide 4

Treatment Considerations

Efficacy Comparison

• Budesonide is superior to mesalamine for clinical remission, especially after 8 weeks (RR 2.29 vs 1.7) 3
• Budesonide is associated with fewer adverse events than mesalamine 3
• Symptom relapse occurs in 46-80% of patients within 6 months of stopping budesonide 4

Treatment Pitfalls

• High relapse rate: Nearly half to 80% of patients relapse within 6 months of stopping treatment 4
• Bone health concerns: Consider osteoporosis prevention and screening for patients on long-term budesonide 1
• Medication review: Identify and discontinue medications that may trigger microscopic colitis (especially proton pump inhibitors) 5
• Smoking cessation: Recommend smoking cessation as it may contribute to disease 5

Refractory Disease

• For patients who don't respond to standard therapies:
  • Consider immunosuppressants (azathioprine, 6-mercaptopurine) 1, 6
  • Anti-TNF agents may benefit some patients 1, 6
  • Evidence for these agents is limited to case series 1

Treatment Algorithm

1. Initial presentation: Start budesonide 9 mg daily for 8 weeks
2. If remission achieved: Discontinue therapy and monitor
3. If symptoms recur: Restart budesonide 6 mg daily for maintenance
4. If budesonide not feasible: Try mesalamine, bismuth salicylate, or prednisolone in that order
5. For refractory disease: Consider immunosuppressants or anti-TNF agents

Remember that maintenance therapy should only be offered to patients who relapse after induction therapy, as up to one-third of patients may not require it 1.