What is the initial treatment regimen for patients with colitis?

Initial Treatment Regimen for Colitis

For patients with colitis, the initial treatment regimen should include oral mesalazine 2-4g daily combined with topical mesalazine for distal disease, with escalation to oral prednisolone 40mg daily for moderate to severe disease or inadequate response to mesalazine. 1

Treatment Based on Disease Severity and Extent

Mild to Moderate Colitis

1. First-line therapy:

   • Oral mesalazine (5-ASA) 2-4g daily or balsalazide 6.75g daily 1
   • For distal disease (up to sigmoid-descending junction): Add topical mesalazine 1g daily in appropriate formulation 2
   • Combination of oral and topical mesalazine is more effective than either agent alone 2

2. If inadequate response after 2 weeks:

   • Escalate to oral prednisolone 40mg daily 2
   • Continue topical agents as adjunctive therapy 2
   • Taper prednisolone gradually over 8 weeks to prevent early relapse 2

Moderate to Severe Colitis

1. Initial treatment:

   • Oral prednisolone 40mg daily 2, 1
   • Taper gradually according to response, typically over 8 weeks 2
   • Consider adding topical therapy for symptomatic relief 2

2. For steroid-dependent disease:

   • Azathioprine 1.5-2.5 mg/kg/day or mercaptopurine 0.75-1.5 mg/kg/day 2, 1
   • Note: These have slow onset of action (up to 3 months) and cannot be used as sole therapy 2

Severe Colitis Requiring Hospitalization

1. Immediate management:

   • Intravenous steroids (hydrocortisone 400mg/day or methylprednisolone 60mg/day) 2, 1
   • Daily monitoring of vital signs, stool frequency, and laboratory parameters 1
   • Joint management with colorectal surgeon 1

2. If no improvement within 72 hours:

   • Consider rescue therapy with infliximab 5 mg/kg (induction at 0,2, and 6 weeks) 1, 3 or cyclosporine 2
   • Surgical evaluation for potential colectomy 2, 1

Special Considerations

Distal Colitis (Proctitis or Left-sided Colitis)

• Topical mesalazine is more effective than topical corticosteroids 2
• Topical corticosteroids should be reserved as second-line therapy for patients intolerant to topical mesalazine 2
• Proximal constipation should be treated with stool bulking agents or laxatives 2

Maintenance Therapy After Remission

• Oral mesalazine 2-4g daily for maintenance 1
• For steroid-dependent disease: Azathioprine or mercaptopurine 2, 1
• For biologic-induced remission: Continue biologic therapy 1

Common Pitfalls to Avoid

1. Inadequate initial dosing of mesalazine - Start with full therapeutic doses (2-4g daily) rather than low doses with escalation 4

2. Delayed escalation of therapy - If no improvement after 2 weeks of mesalazine, promptly escalate to steroids 2

3. Prolonged steroid use - Implement steroid-sparing strategies with azathioprine/mercaptopurine for steroid-dependent disease 1

4. Failure to rule out infectious causes - Always obtain stool studies (culture, C. difficile, parasites) before initiating therapy 1

5. Delaying surgical consultation - Involve surgeons early in severe disease management 1

The treatment approach for colitis should be guided by disease severity, extent of inflammation, and response to initial therapy. Early recognition of treatment failure and timely escalation of therapy are crucial for improving outcomes and preventing complications.