What are the treatment options for colitis?

Treatment Options for Colitis

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

First-Line Therapy

• Mild to Moderate Disease:

  • Combination of topical mesalamine (1g daily) with oral mesalamine (2-4g daily) is recommended 1
  • Topical formulation should match the disease extent
  • For ulcerative proctitis and left-sided colitis, rectal 5-ASA preparations are more effective than oral administration alone 2

• Moderate to Severe Disease:

  • Oral prednisolone 40mg daily with tapering over 6-8 weeks 1
  • Budesonide MMX 9mg daily can be considered as an alternative to systemic steroids with fewer side effects 1

Treatment Escalation Algorithm

1. Initial Assessment (4-8 weeks after starting therapy):

   • Monitor stool frequency, presence of blood, and inflammatory markers (CRP)
   • If inadequate response to 5-ASA, proceed to corticosteroids

2. Steroid Therapy:

   • Oral prednisolone 40mg daily with tapering over 6-8 weeks
   • IV methylprednisolone 60mg/day or hydrocortisone 100mg four times daily for severe cases

3. Steroid Response Evaluation:

   • Assess response to oral steroids within 2 weeks
   • For IV corticosteroids, formal assessment on day 3 of therapy
   • Failure criteria: >8 stools/day or 3-8 stools with CRP >45 mg/L on day 3

4. For Steroid-Refractory Disease:

   • Consider rescue therapy with infliximab or cyclosporine 1, 3
   • Infliximab induction: 5mg/kg at weeks 0,2, and 6, followed by maintenance of 5mg/kg every 8 weeks 3
   • If no improvement after 4-7 days of salvage therapy, consider colectomy

5. For Steroid-Dependent Disease:

   • Escalate to immunomodulators: azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.5 mg/kg/day) 1
   • Consider biologics (infliximab), vedolizumab, or tofacitinib 1

Surgical Management

• Consider surgery for disease not responding to intensive medical therapy
• Procedure of choice in acute fulminant colitis: subtotal colectomy with ileostomy 1
• Principles for surgical management:
  • Preserve maximum possible length of intestine
  • Limit resection to macroscopically affected segment
  • Avoid primary anastomosis in presence of sepsis or malnutrition

Diagnostic Workup

• Complete blood count, inflammatory markers (CRP or ESR)
• Electrolytes and liver function tests
• Stool sample for culture and C. difficile toxin assay
• Plain abdominal radiograph to exclude colonic dilatation (≥5.5 cm)
• Flexible sigmoidoscopy to confirm diagnosis and assess disease severity

Common Pitfalls to Avoid

• Inadequate initial dosing of prednisolone (<40 mg daily) is less effective for moderate to severe disease 1
• Delayed assessment of response to steroids can delay necessary treatment escalation 1
• Prolonged steroid use without steroid-sparing strategies leads to increased adverse effects 1
• Opioid use should be avoided when possible due to risks of dependence, infection, narcotic bowel syndrome, and gut dysmotility 1
• Failure to screen for tuberculosis and other infections before starting biologics like infliximab 3

Special Considerations

• For patients on infliximab, treatment for latent tuberculosis should be initiated prior to starting therapy 3
• Monitor for invasive fungal infections in patients on biologics, especially those on immunosuppressants 3
• Be aware of increased risk of lymphoma and other malignancies in patients treated with TNF blockers, particularly when combined with azathioprine or 6-mercaptopurine 3
• Regular surveillance colonoscopies are recommended after 8-10 years of disease (every 3 years in second decade, every 2 years in third decade, annually in fourth decade) 1