What is the recommended treatment approach for microscopic colitis?

Treatment Approach for Microscopic Colitis

Budesonide is the first-line treatment for symptomatic microscopic colitis, recommended at a dose of 9 mg daily for 8 weeks. 1

Initial Management Steps

1. Identify and discontinue potential triggers:

   • NSAIDs, PPIs, SSRIs (particularly sertraline), and statins 1
   • Eliminate caffeine and assess for lactose intolerance 2
   • Counsel on smoking cessation if applicable 1

2. Symptomatic relief:

   • Loperamide for immediate symptom management (though may have limited efficacy) 2, 3

Treatment Algorithm Based on Symptom Severity

Mild Disease

• Antidiarrheals (loperamide) as initial therapy 4
• Consider bismuth salicylate (8-9 tablets divided 3 times daily) if antidiarrheals fail 1

Moderate to Severe Disease

1. First-line: Budesonide 9 mg daily for 8 weeks 1, 4

   • Most effective for both induction and maintenance therapy
   • Monitor for bone health concerns with prolonged use

2. Second-line: Mesalamine 2-4 g daily 1, 2

   • Less effective than budesonide but reasonable alternative
   • Prefer newer 5-ASA formulations over sulfasalazine due to fewer side effects

3. Third-line options:

   • Bile acid sequestrants (cholestyramine) - particularly effective if bile acid diarrhea is present 1, 2
   • Prednisolone/prednisone - when budesonide cost is prohibitive 1

4. Refractory disease options:

   • Immunomodulators (azathioprine, 6-mercaptopurine) 1, 4
   • Anti-TNF agents in selected cases 1, 3
   • Consider surgical intervention (fecal stream diversion or subtotal colectomy) as last resort 2

Management of Associated Conditions

• Bile acid diarrhea: Present in 41% of collagenous colitis and 29% of lymphocytic colitis cases 1

  • Treatment: Cholestyramine or other bile acid sequestrants

• Celiac disease: Screen for this condition, present in 5-7% of microscopic colitis patients 1

  • Essential to rule out in patients with persistent symptoms

Maintenance Therapy

• For patients with recurrent symptoms, consider low-dose budesonide for maintenance 4
• Consider discontinuation of budesonide after 6-12 months 1
• Monitor for bone loss with prolonged budesonide use 1

Common Pitfalls to Avoid

1. Failing to obtain biopsies from multiple segments of the colon during diagnosis (rectal biopsies alone may miss the disease) 1

2. Overlooking associated conditions like celiac disease or bile acid diarrhea in patients with persistent symptoms 1

3. Continuing potential medication triggers in patients with refractory symptoms 1, 3

4. Neglecting bone health monitoring in patients on long-term budesonide therapy 1

5. Missing incomplete forms of microscopic colitis that may be overlooked in routine clinical settings 5

The treatment approach should be guided by symptom severity, with budesonide being the cornerstone of therapy for moderate to severe disease, while addressing medication triggers and associated conditions remains essential for optimal management.