What are the treatment options for colitis, specifically ulcerative colitis or Crohn's disease?

Treatment Options for Colitis (Ulcerative Colitis and Crohn's Disease)

For ulcerative colitis, 5-aminosalicylates (5-ASA) are the first-line treatment for mild to moderate disease, while corticosteroids, immunomodulators, and biologics are recommended for more severe or refractory cases. 1

Ulcerative Colitis Treatment

Mild to Moderate Disease

• First-line therapy: Oral mesalazine (5-ASA) 2-4g daily combined with topical mesalazine 1g daily 2, 1
  • For proctitis: 1g 5-ASA suppository daily 2
  • For left-sided colitis: Combination of oral and rectal 5-ASA is more effective than either alone 1
  • Higher doses (4g/day) may be more effective for moderate disease 2

Moderate to Severe Disease

• For inadequate response to 5-ASA: Oral prednisolone 40mg daily with gradual taper over 8 weeks 2, 1
• For steroid-dependent disease: Azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.5 mg/kg/day) 1
  • Note: Risk of hepatosplenic T-cell lymphoma with azathioprine, particularly in young males 3
• For steroid-resistant/dependent disease: Anti-TNF therapy (infliximab, adalimumab, golimumab) or vedolizumab 2, 1
  • Infliximab carries increased risk of lymphoma and other malignancies 4

Severe Acute Colitis (Hospitalized Patients)

• Intravenous methylprednisolone 40-60mg/day or equivalent 2
• Daily monitoring of vital signs, stool frequency, and laboratory parameters 2
• If no improvement after 3-5 days: Consider rescue therapy with infliximab or cyclosporine 2, 1
• Joint management with colorectal surgeon; 25-30% may require colectomy 2

Crohn's Disease Treatment

Mild to Moderate Disease

• For mild ileocolonic disease: High-dose mesalazine (4g/day) may be sufficient initial therapy, though evidence for 5-ASA in Crohn's is limited 2, 5, 6
• For moderate disease or inadequate response to 5-ASA: Oral corticosteroids (prednisolone 40mg daily) 2
• For isolated ileo-cecal disease: Budesonide 9mg daily (less effective than prednisolone but fewer side effects) 2

Moderate to Severe Disease

• Oral corticosteroids for induction of remission 2
• For maintenance: Immunomodulators (azathioprine, mercaptopurine) or biologics 2, 1
• For steroid-dependent/resistant disease: Anti-TNF therapy or vedolizumab 2, 1

Fistulizing Disease

• Total parenteral nutrition as adjunctive therapy 2
• Anti-TNF therapy (particularly infliximab) 2

Maintenance Therapy

Ulcerative Colitis

• Lifelong maintenance therapy recommended for most patients 2, 1
• 5-ASA compounds (2-4g daily) for mild to moderate disease 2, 1
• Azathioprine or mercaptopurine for those who cannot maintain remission on 5-ASA 1
• Continue biologics in those who responded to induction therapy 2

Crohn's Disease

• Maintenance therapy with immunomodulators or biologics based on disease severity and response to induction 2, 1
• Limited evidence for 5-ASA in maintaining remission in Crohn's disease 5, 6

Important Considerations and Pitfalls

• Disease assessment: Confirm active inflammation with endoscopy and exclude infection before treatment 1
• Combination therapy: Consider risks of combined immunosuppression (particularly increased malignancy risk) 4, 3
• Monitoring: Regular laboratory monitoring for patients on immunomodulators or biologics 1
• Surgery indications: Free perforation, life-threatening hemorrhage, toxic megacolon with clinical deterioration 1
• Common pitfalls:
  • Inadequate dosing of 5-ASA compounds
  • Prolonged steroid use without appropriate steroid-sparing strategies
  • Failure to recognize infectious causes of colitis
  • Delaying surgical consultation in severe disease 1

The treatment approach should be based on disease location, severity, and pattern, with regular assessment of response to optimize outcomes and minimize complications.