What are the treatment options for colitis, specifically ulcerative colitis or Crohn's disease?

Treatment Options for Colitis (Ulcerative Colitis and Crohn's Disease)

The first-line treatment for ulcerative colitis is a combination of topical mesalamine (1g daily) with oral mesalamine (2-4g daily), while Crohn's disease is primarily treated with topical steroids such as budesonide. 1

Ulcerative Colitis Treatment Algorithm

Mild to Moderate Disease

1. First-line therapy:

   • Combination of topical mesalamine (1g daily) with oral mesalamine (2-4g daily) 1
   • For proctitis: Mesalamine suppositories (1g daily) 1
   • Once-daily dosing of oral mesalamine is as effective as divided doses and may improve compliance 1

2. If inadequate response to optimized 5-ASA therapy:

   • Add oral prednisone or budesonide MMX 1
   • Consider immunomodulators (azathioprine 1.5-2.5 mg/kg/day or mercaptopurine 0.75-1.5 mg/kg/day) for steroid-dependent disease 1

3. For steroid-refractory cases:

   • Consider biologics such as infliximab 1
   • Alternative: cyclosporine 1

Severe Disease

1. Intravenous corticosteroids:

   • Methylprednisolone 60 mg/day IV or hydrocortisone 100 mg four times daily 1

2. If no improvement within 3-5 days:

   • Consider infliximab or cyclosporine 1
   • Early surgical consultation 1

3. Surgical options:

   • Subtotal colectomy with ileostomy is the procedure of choice for emergency surgery 1

Crohn's Disease Treatment Approach

1. Mild disease:

   • Topical steroids such as budesonide are primarily used 2
   • High-dose 5-ASA has limited effectiveness but may be considered 2, 3
   • 5-ASA is beneficial for postoperative recurrence prevention 2

2. Moderate to severe disease:

   • Corticosteroids for acute flares 1
   • Immunomodulators for steroid-dependent disease 1
   • Biologics for steroid-refractory cases 1, 4

Medication Details and Monitoring

5-Aminosalicylates (5-ASA)

• Dosing: Oral doses of 2-4g daily, topical doses of 1g daily 1
• Formulations: Mesalamine, balsalazide, sulfasalazine
• Monitoring: Periodic renal function tests 1
• Efficacy: Well-documented for ulcerative colitis; modest at best for Crohn's disease 3

Corticosteroids

• Dosing: Prednisolone 40mg daily with gradual taper over 8 weeks 1
• Limitations: Not suitable for long-term use due to side effects 1
• Special consideration: Budesonide has fewer systemic side effects

Immunomodulators

• Azathioprine: 1.5-2.5 mg/kg/day 1, 5
• Mercaptopurine: 0.75-1.5 mg/kg/day 1
• Monitoring: Complete blood counts weekly during first month, twice monthly for second and third months, then monthly 5
• Warning: Risk of hepatosplenic T-cell lymphoma, especially in young males with Crohn's disease or ulcerative colitis when combined with TNF blockers 5

Biologics (e.g., Infliximab)

• Indications: Steroid-refractory cases 1
• Warnings: Increased risk of lymphoma and other malignancies, particularly in children and young adults 4
• Monitoring: Screen for tuberculosis before initiation, monitor for infections during treatment 4

Disease Monitoring Recommendations

• Evaluate symptomatic response within 4-8 weeks of initiating therapy 1
• Monitor disease activity using fecal calprotectin (remission: <150 mg/g) 1
• Regular laboratory tests: complete blood count, inflammatory markers (CRP or ESR), electrolytes, liver function tests 1
• Colonoscopy after 8-10 years to re-evaluate disease extent, with regular surveillance colonoscopies thereafter 1

Common Pitfalls to Avoid

• Delayed treatment escalation in non-responders 1
• Prolonged steroid use without steroid-sparing strategies 1
• Failure to recognize infectious causes of symptoms 1
• Delayed surgical consultation in severe cases 1
• Opioid use due to risks of dependence, infection, narcotic bowel syndrome, and gut dysmotility 1
• Combination therapy risks: Azathioprine with TNF blockers increases risk of hepatosplenic T-cell lymphoma, particularly in young males 4, 5
• Underutilization of topical therapy in ulcerative colitis, as rectal 5-ASA preparations are more effective than oral administration alone in proctitis and left-sided colitis 2

Special Considerations

• Cancer risk: Regular skin examinations for patients on TNF blockers due to increased risk of melanoma and other skin cancers 4, 5
• Cervical cancer screening: Women on infliximab should undergo periodic screening due to 2-3 fold increased risk 4
• TPMT or NUDT15 deficiency: Consider testing before starting azathioprine to avoid severe myelotoxicity 5
• Pregnancy: Azathioprine should be avoided during pregnancy if possible 5

By following this treatment algorithm and monitoring recommendations, clinicians can optimize outcomes for patients with ulcerative colitis and Crohn's disease while minimizing treatment-related complications.