What is the treatment approach for patients with colitis?

Treatment Approach for Colitis

The first-line therapy for ulcerative colitis is a combination of topical mesalamine (1g daily) with oral mesalamine (2-4g daily), with the topical formulation matching the disease extent. 1

Classification and Initial Treatment

Mild to Moderate Ulcerative Colitis

• First-line therapy:
  • Oral mesalamine 2-4g daily (start at higher dose of 4.8g rather than escalating from lower doses) 1, 2
  • Combined with topical mesalamine 1g daily (suppositories for proctitis, enemas for left-sided disease) 1
  • Once-daily dosing is as effective as divided doses and improves compliance 1

Moderate to Severe Disease

• If inadequate response to optimized 5-ASA therapy:
  • Add oral prednisone (40mg daily with gradual taper over 8 weeks) or budesonide MMX 1
  • For steroid-dependent disease: Consider immunomodulators like azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.5 mg/kg/day) 1
  • For steroid-refractory cases: Consider biologics such as infliximab 1, 3

Severe Acute Colitis

• Intravenous corticosteroids (methylprednisolone 60 mg/day or hydrocortisone 100 mg four times daily) 1
• Early surgical consultation if not responding to medical therapy 1
• Consider infliximab or cyclosporine for steroid-refractory cases 1, 3

Medication-Specific Considerations

Aminosalicylates (5-ASA)

• Dosing:
  • Oral: 2-4g daily (high-dose >3g/day shows better efficacy) 1
  • Topical: 1g daily 1
• Monitoring: Periodic renal function tests 1
• Special cases: Sulfasalazine (2-4g daily) is particularly effective for patients with associated reactive arthropathy 1

Infliximab (for moderate-severe disease)

• Dosing: 5 mg/kg at weeks 0,2, and 6, then every 8 weeks 3
• Indications: Moderately to severely active ulcerative colitis with inadequate response to conventional therapy 3
• Important warnings:
  • Screen for tuberculosis before starting therapy 3
  • Monitor for serious infections and discontinue if they develop 3
  • Risk of lymphoma and other malignancies, particularly hepatosplenic T-cell lymphoma in young males with IBD on concurrent azathioprine/6-MP 3

Disease Monitoring

• Evaluate symptomatic response within 4-8 weeks of initiating therapy 1
• Monitor disease activity using:
  • Fecal calprotectin (remission: <150 mg/g) 1
  • Complete blood count, inflammatory markers (CRP or ESR), electrolytes, liver function tests 1
  • Stool samples for culture and C. difficile toxin assay 1
• Perform flexible sigmoidoscopy to confirm diagnosis and assess disease severity 1
• Colonoscopy after 8-10 years to re-evaluate disease extent, then regular surveillance colonoscopies 1

Treatment Optimization

• For patients who relapse on low-dose maintenance therapy (1.5-2.25g/day), increasing mesalamine to 4.0g/day is safe and effective 4
• Combination of topical and oral mesalamine is more effective than either treatment alone 1
• Consider surgery for:
  • Failure of medical therapy
  • Complications
  • Limited ileal or ileocecal disease as primary therapy 1

Common Pitfalls to Avoid

• Avoid opioids when possible due to risks of dependence, infection, narcotic bowel syndrome, and gut dysmotility 1
• Avoid delaying treatment escalation in non-responders 1
• Avoid prolonged steroid use without steroid-sparing strategies 1
• Avoid failure to recognize infectious causes of symptoms 1
• Avoid delaying surgical consultation in severe cases 1
• Avoid routine use of antibiotics without evidence of infection 1

Special Considerations

• In the era of biologics, aminosalicylates remain first-line therapy for mild UC and should be considered for moderate UC without poor prognostic factors 5
• For emergency surgery in acute severe ulcerative colitis, subtotal colectomy with ileostomy is the procedure of choice 1
• Mesalamine is considered safe in pregnancy, excluding formulations with dibutyl phthalate 6