What medications are used to treat colitis?

Medications for Colitis Treatment

For colitis treatment, aminosalicylates (5-ASA) such as mesalamine are the first-line therapy for mild to moderate disease, with corticosteroids reserved for more severe cases or those unresponsive to 5-ASA therapy. 1

Treatment Algorithm Based on Disease Extent and Severity

Distal Colitis (Proctitis/Proctosigmoiditis)

• First-line therapy: Combination of topical mesalamine (1g daily) with oral mesalamine (2-4g daily) 1, 2

  • Topical formulation should match disease extent:
    • Suppositories for proctitis (rectum only)
    • Foam or liquid enemas for more proximal disease
  • Topical mesalamine is superior to topical corticosteroids 1

• Second-line therapy: Topical corticosteroids for patients intolerant to topical mesalamine 1

• Third-line therapy: Oral prednisolone 40mg daily if no improvement with combination therapy 1

  • Gradually taper over 8 weeks according to response

Left-sided or Extensive Colitis

• First-line therapy: Oral mesalamine 2-4g daily or balsalazide 6.75g daily 1

  • High-dose mesalamine (>3g/day) shows better efficacy than standard doses 1
  • Once-daily dosing improves adherence and has better remission rates than twice-daily dosing 3

• Second-line therapy: Prednisolone 40mg daily for patients requiring prompt response or when mesalamine is unsuccessful 1

  • Taper gradually over 8 weeks

• Add-on therapy: Topical mesalamine or corticosteroids may provide additional benefit for rectal symptoms 1

Severe Ulcerative Colitis

• Hospital admission for intravenous therapy when:

  • Failed response to maximal oral treatment
  • Severe disease by Truelove and Witts' criteria 1

• Treatment approach:

  • IV fluid and electrolyte replacement
  • IV corticosteroids (methylprednisolone or hydrocortisone) 2
  • Ciclosporin for steroid-refractory cases 1
  • Close monitoring of vital signs, stool frequency, and laboratory values
  • Early surgical consultation

Advanced Therapy Options

For patients with inadequate response to standard therapies:

• For moderate-to-severe UC: Tofacitinib (Xeljanz) for patients with inadequate response to TNF blockers 4
  • Induction: 10mg twice daily for 8-16 weeks
  • Maintenance: 5mg twice daily
  • Extended-release formulations available

Medication Formulations

5-ASA Medications

• Mesalamine (multiple delivery mechanisms):

  • Delayed-release tablets (pH-dependent release in distal ileum/colon)
  • Controlled-release tablets (delivery beginning in duodenum)
  • MMX formulation (delayed and extended delivery throughout lower bowel)
  • Capsules with enteric-coated granules 1

• Diazo-bonded 5-ASA:

  • Olsalazine (Dipentum): Two 5-ASA moieties joined by azo bond
  • Balsalazide (Colazal): 5-ASA linked to inert carrier molecule 1

• Sulfasalazine: 5-ASA linked to sulfapyridine (higher side effect profile) 1

Common Pitfalls and Considerations

1. Dosing pitfalls:

   • Underdosing mesalamine is common - efficacy is dose-dependent 5
   • For active disease, 4.8g/day is more effective than 2.4g/day 5
   • For maintenance, 2.4g/day is recommended 5

2. Administration considerations:

   • Once-daily dosing improves adherence and outcomes compared to divided doses 3
   • Different mesalamine formulations are not interchangeable due to different release profiles 6

3. Monitoring requirements:

   • Periodic renal function monitoring 1
   • Monitor for rare idiosyncratic reactions (hypersensitivity, interstitial nephritis) 1

4. Treatment duration:

   • Maintenance therapy should be continued long-term to prevent relapse 1
   • Mesalamine has a safety profile comparable to placebo for long-term use 6

5. Combination therapy:

   • For distal disease, combined oral and topical therapy is more effective than either alone 1
   • Proximal constipation should be treated with stool bulking agents or laxatives 1

By following this evidence-based approach to colitis treatment, focusing on disease extent and severity, patients can achieve optimal symptom control and disease remission with minimal side effects.