What is the treatment for ileitis?

Treatment of Ileitis

The first-line treatment for ileitis is oral and/or rectal 5-ASA (mesalamine) at 2-4g/day, with oral prednisolone 40 mg daily as an alternative for those who are 5-ASA intolerant or fail to respond within 4-8 weeks. 1

First-Line Treatment Options

Mesalamine Therapy

• Oral mesalamine 2-4g daily is recommended as initial therapy
• For distal disease, combine with topical mesalamine (1g daily)
• Response should be assessed within 4-8 weeks of initiating therapy
• Mesalamine in microgranular formulation has shown efficacy comparable to steroids in mild to moderate ileitis 2

Corticosteroid Therapy

• For patients who fail to respond to mesalamine or have moderate-severe disease:
  • Oral prednisolone 40 mg daily with tapering over 6-8 weeks
  • Budesonide MMX 9 mg daily can be considered as an alternative with fewer systemic side effects
  • Evaluate response to oral steroids within 2 weeks
  • For intravenous therapy: methylprednisolone 60 mg/day or hydrocortisone 100 mg four times daily

Treatment Escalation Algorithm

1. Initial therapy failure (no response within 4-8 weeks):

   • Escalate to corticosteroids if started on mesalamine

2. Steroid-dependent disease:

   • Consider immunomodulators: azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.5 mg/kg/day)

3. Steroid-refractory disease (no response by day 3 of IV steroids):

   • Consider biologics: infliximab 5 mg/kg at weeks 0,2, and 6, then every 8 weeks 1, 3
   • Alternative: cyclosporine

4. Severe, refractory disease:

   • Surgical consultation if no improvement after 4-7 days of salvage therapy

Monitoring Response

• Assess stool frequency, presence of blood, and inflammatory markers (CRP)
• For IV corticosteroids, formal assessment on day 3 of therapy
• Failure criteria: >8 stools per day or 3-8 stools with CRP >45 mg/L on day 3

Surgical Management

• Consider surgery for disease not responding to intensive medical therapy
• Preserve maximum possible length of intestine
• Limit resection to macroscopically affected segments
• Avoid primary anastomosis in presence of sepsis or malnutrition
• Subtotal colectomy with ileostomy is the procedure of choice for emergency surgery

Important Considerations and Pitfalls

Diagnostic Considerations

• Ileitis may be caused by conditions other than Crohn's disease, including infectious diseases, spondyloarthropathies, vasculitides, ischemia, and medication-induced inflammation 4, 5
• Complete diagnostic workup should include:
  • Complete blood count
  • Inflammatory markers (CRP or ESR)
  • Electrolytes and liver function tests
  • Stool sample for culture and C. difficile toxin assay

Common Pitfalls to Avoid

• Inadequate initial dosing of prednisolone (<40 mg daily) is less effective
• Delayed assessment of response can delay necessary treatment escalation
• Missing steroid-sparing strategies in steroid-dependent patients
• Routine use of antibiotics without evidence of infection
• Opioid use should be avoided when possible due to risks of dependence, infection, narcotic bowel syndrome, and gut dysmotility

Special Considerations with Biologics

• Infliximab warnings 3:
  • Increased risk of serious infections (TB, bacterial sepsis, invasive fungal infections)
  • Risk of lymphoma and other malignancies, particularly hepatosplenic T-cell lymphoma in young males with Crohn's disease or ulcerative colitis on concurrent immunosuppressants
  • Perform TB testing before initiating therapy
  • Discontinue if serious infection develops

Treatment of Prepouch Ileitis

• Prepouch ileitis (inflammation in the afferent ileum proximal to an ileal pouch) requires more aggressive therapy than isolated pouchitis 6
• Less responsive to antibiotics (only 27% respond)
• Often requires escalation to steroids, immunomodulators, or anti-TNF agents (54% of cases)
• Consider early immunomodulatory therapy in cases of non-response to antibiotics