What is the treatment for colitis?

Treatment for Colitis

For mild to moderately active ulcerative colitis, the first-line treatment is a combination of oral mesalazine ≥ 2.4 g/day plus topical mesalazine 1 g/day, with the topical formulation matching the extent of disease. 1, 2

Treatment Algorithm Based on Disease Extent and Severity

Distal Colitis (Proctitis/Left-sided)

1. First-line therapy:

   • Topical mesalazine 1 g/day (suppositories for proctitis, foam/liquid enemas for more proximal disease) 1
   • PLUS oral mesalazine 2-4 g/day 1, 2
   • Once-daily dosing is as effective as divided doses 1, 3

2. Second-line therapy (if intolerant to topical mesalazine):

   • Topical corticosteroids (less effective than topical mesalazine) 1
   • Continue oral mesalazine

3. Third-line therapy (if no response to above):

   • Oral prednisolone 40 mg daily with gradual taper over 8 weeks 1, 2
   • Continue topical therapy as adjunctive treatment 1

Extensive Colitis

1. First-line therapy:

   • Oral mesalazine 2-4 g/day 1, 2
   • PLUS topical mesalazine 1 g/day if tolerated 1

2. Second-line therapy (moderate-severe or no response to mesalazine):

   • Oral prednisolone 40 mg daily with gradual taper over 8 weeks 1, 2

3. For steroid-dependent disease:

   • Azathioprine 1.5-2.5 mg/kg/day or mercaptopurine 0.75-1.5 mg/kg/day 1, 2

Severe Colitis (requiring hospitalization)

1. Intensive intravenous therapy:

   • IV hydrocortisone 400 mg/day or methylprednisolone 60 mg/day 1, 2
   • IV fluid and electrolyte replacement 1
   • Blood transfusion to maintain hemoglobin >10 g/dl 1
   • Subcutaneous heparin for thromboembolism prophylaxis 1, 2
   • Daily monitoring of vital signs, stool frequency, and laboratory parameters 1

2. If no improvement within 72 hours:

   • Consider second-line therapy (infliximab or ciclosporin) 2, 4
   • Surgical consultation 1, 2

Maintenance Therapy

• Lifelong maintenance therapy with oral mesalazine 2-4 g/day is recommended to prevent relapse and reduce colorectal cancer risk 1, 2
• For those who cannot maintain remission on mesalazine, azathioprine or mercaptopurine is recommended 1, 2

Special Considerations

Budesonide MMX

• Budesonide MMX 9 mg/day can be effective for mild-moderate left-sided UC inadequately controlled with 5-ASA 1
• Not effective for extensive colitis 1

Biological Therapy

• Infliximab (5 mg/kg at 0,2, and 6 weeks, then every 8 weeks) is indicated for moderately to severely active UC with inadequate response to conventional therapy 2, 4

Common Pitfalls to Avoid

1. Inadequate dosing of mesalazine - Ensure doses of at least 2.4 g/day orally 1, 5
2. Failure to combine oral and topical therapy - Combination is more effective than either alone 1
3. Prolonged steroid use - Should be tapered over 8 weeks; implement steroid-sparing strategies for steroid-dependent disease 1, 2
4. Delayed escalation of therapy - Recognize non-responders early (younger age, extensive colitis, early need for steroids are risk factors) 5
5. Delaying surgery in critically ill patients - Maintain close collaboration with surgical team 1, 2
6. Poor adherence to medication - Once-daily dosing of mesalazine is as effective as divided doses and may improve adherence 1, 3, 5

By following this structured approach based on disease extent and severity, most patients with colitis can achieve remission and maintain a good quality of life with appropriate treatment.