What are the treatment options for colitis?

Treatment Options for Colitis

The treatment of colitis should follow a stepwise approach based on disease severity, with first-line therapy for mild to moderate disease including oral mesalazine (2-4g daily) or balsalazide (6.75g daily), combined with topical mesalazine for distal disease. 1

Classification and Initial Assessment

• Colitis severity is typically classified as:

  • Mild to moderate
  • Moderate to severe
  • Acute severe ulcerative colitis (ASUC) requiring hospitalization

• Essential diagnostic workup includes:

  • Stool studies (culture, C. difficile testing, parasites, viral pathogens)
  • Endoscopy for diagnosis and assessing disease severity
  • Laboratory tests (CBC, CRP, ESR, electrolytes, albumin, liver function)
  • Abdominal radiography if colonic dilatation is present (>5.5 cm)

Treatment Algorithm by Disease Severity

Mild to Moderate Disease

1. First-line therapy:

   • Oral mesalazine 2-4g daily or balsalazide 6.75g daily 1
   • For distal colitis: Add topical mesalazine 1g daily to oral therapy 1

2. If inadequate response after 2 weeks:

   • Escalate to oral prednisolone 40mg daily
   • Continue topical agents as adjunctive therapy 1

Moderate to Severe Disease

1. First-line therapy:

   • TNF-α antagonists (infliximab)
   • Anti-integrin agent (vedolizumab)
   • Janus kinase inhibitor (tofacitinib)
   • Immunomodulators (thiopurines, methotrexate) 2

2. For steroid-dependent disease:

   • Azathioprine 1.5-2.5 mg/kg/day or mercaptopurine 0.75-1.5 mg/kg/day 1
   • Note: These have slow onset and cannot be used as sole therapy

3. Infliximab dosing:

   • 5 mg/kg at weeks 0,2, and 6, then every 8 weeks 3
   • Some patients may benefit from dose escalation to 10 mg/kg if they lose response 3

Acute Severe Ulcerative Colitis (Hospitalized Patients)

1. Initial management:

   • Intravenous corticosteroids
   • Daily monitoring of vital signs, stool frequency, and laboratory parameters
   • Subcutaneous heparin for thromboembolism prophylaxis
   • Nutritional support if malnourished 1

2. If no improvement within 72 hours:

   • Consider rescue therapy with infliximab or cyclosporine 1
   • Surgical evaluation for potential colectomy

3. Indications for urgent surgical intervention:

   • Free perforation
   • Life-threatening hemorrhage with hemodynamic instability
   • Generalized peritonitis
   • Toxic megacolon with clinical deterioration
   • Failure to respond to medical therapy within 48-72 hours 1
   • Preferred surgical approach: Subtotal colectomy with ileostomy 1, 4

Maintenance Therapy

• Most drugs initiated for induction of remission are continued as maintenance therapy if effective 2

• Options include:

  • Oral mesalazine 2-4g daily
  • Azathioprine or mercaptopurine
  • Biologics (infliximab, vedolizumab)
  • Tofacitinib 1

• Lifelong maintenance therapy is generally recommended to prevent disease relapse 1

Special Considerations and Precautions

Infliximab Safety Concerns

• Increased risk of serious infections including tuberculosis, bacterial sepsis, and invasive fungal infections
• Risk of lymphoma and other malignancies, particularly hepatosplenic T-cell lymphoma in young males with Crohn's or UC who receive concomitant azathioprine/6-mercaptopurine
• Perform TB testing before starting therapy 3

Common Pitfalls to Avoid

• Delayed escalation of therapy when response is inadequate
• Inadequate dosing of 5-ASA compounds
• Prolonged steroid use without appropriate steroid-sparing strategies
• Failure to recognize infectious causes of colitis
• Delayed surgical consultation in severe disease 1
• Opioids should be avoided due to risks of dependence, infection, and gut dysmotility 1

Monitoring Response

• Daily monitoring of vital signs, stool frequency, and laboratory parameters in acute severe cases
• Mucosal healing on repeat endoscopy and/or fecal calprotectin level ≤116 mg/g can guide decisions on when to adjust or stop biologic treatment 1

The treatment approach should be aggressive for moderate to severe disease, as 20% of patients may require hospitalization, and the 5-10 year cumulative risk of colectomy is 10-15% for these patients 2. Emergency surgery should not be seen as a last resort but as a potentially life-saving procedure when medical therapy fails 4.