From the Guidelines
The management of steroid-induced colitis requires a stepwise approach, starting with corticosteroids, and potentially adding biologics such as infliximab or vedolizumab for refractory cases, as recommended by the most recent guidelines 1.
Initial Management
The initial management of steroid-induced colitis involves administering corticosteroids, with an initial dose of 1-2 mg/kg/day prednisone or equivalent, until symptoms improve to grade 1, and then starting a taper over 4-6 weeks 1.
- Consider hospitalization for patients with dehydration or electrolyte imbalance.
- Consider repeat colonoscopy in patients who are immunosuppression-refractory.
- Should consider permanently discontinuing CTLA-4 agents.
Biologics for Refractory Cases
For patients with high-risk endoscopic features on initial endoscopy examination or inadequate response to steroids, consider early introduction of infliximab or vedolizumab in addition to steroids 1.
- Infliximab is typically dosed at 5 mg/kg given intravenously, and vedolizumab is given intravenously at a 300-mg dose.
- Both infusions are typically given at weeks 0,2, and 6, with a minority of patients receiving longer-term treatment.
Additional Considerations
Additional considerations for the management of steroid-induced colitis include:
- Fecal microbiota transplant, JAK inhibitor tofacitinib, or IL-12–blocking antibody ustekinumab in patients who are refractory to previous immunosuppressants 1.
- Endoscopic evaluation with EGD or colonoscopy is highly recommended for cases grade ≥ 2 to stratify patients for early treatment of biologics based on the endoscopic findings 1.
- Resuming ICPi after symptoms improve to grade 1 may be considered when steroid taper is completed, risk and benefits reviewed if maintained on biologics, and/or if endoscopic and histologic remissions are achieved 1.
From the Research
Management of Steroid-Induced Colitis
There are no research papers to assist in answering this question as the provided studies focus on stercoral colitis, which is a different condition.
Management of Stercoral Colitis
- The management of stercoral colitis depends on the severity of the illness, ranging from manual disimpaction and other conservative measures for most cases, to surgical intervention for complicated cases, such as stercoral perforation 2.
- Urgent treatment with laxatives and fecal disimpaction is indicated to prevent perforation and peritonitis 3.
- ED management includes fluid resuscitation, initiation of a multimodal bowel regimen, and if indicated, initiation of parenteral antibiotics and consultation with a surgical specialist 4.
- Prompt resuscitation and surgical exploration with damage control surgery are recommended for stercoral colitis-induced ischemia 5.
- Most patients with stercoral colitis require hospital admission, and the condition is associated with substantial short-term mortality 6.
Key Considerations
- Stercoral colitis is a rare but serious diagnosis associated with a high rate of morbidity and mortality 4.
- The condition often presents in a nonspecific manner, requiring a high index of suspicion for early diagnosis 3, 5.
- CT scans are crucial for diagnosis, revealing key findings such as fecaloma, colonic dilatation, and fat stranding 2, 6.