What medications are used to treat acute colitis?

Medications for Acute Colitis Treatment

For acute colitis, first-line treatment includes corticosteroids (oral prednisolone 40mg daily or IV methylprednisolone 60mg/day) with stool testing for C. difficile infection and treatment with oral vancomycin 125mg four times daily if positive. 1, 2, 3

Initial Assessment and Diagnosis

• Obtain stool cultures for entero-invasive bacterial infections and C. difficile assay for all patients with acute colitis flares 1
• Perform colonic biopsies in moderate to severe colitis cases to check for cytomegalovirus (CMV) by H&E staining and immunohistochemistry 1
• Monitor stool frequency, presence of blood, and inflammatory markers (CRP) 2
• Assess disease severity with flexible sigmoidoscopy and plain abdominal radiograph to exclude colonic dilatation (≥5.5 cm) 2

Treatment Algorithm

Step 1: First-Line Therapy

• Mild to Moderate Colitis:

  • Oral and/or rectal 5-ASA (mesalamine) 2-4g/day 2
  • Combination of topical mesalamine (1g daily) with oral mesalamine (2-4g daily) for optimal results 2

• Moderate to Severe Colitis:

  • Oral prednisolone 40mg daily with tapering over 6-8 weeks 2
  • Alternative: Budesonide MMX 9mg daily (fewer systemic side effects) 2

• Acute Severe Colitis:

  • IV methylprednisolone 60mg/day or hydrocortisone 100mg four times daily 2
  • Evaluate response by day 3 of therapy 2

Step 2: C. difficile Testing and Treatment

• Test all acute colitis flares for C. difficile infection 1
• If C. difficile positive, treat with oral vancomycin 125mg four times daily for 10 days 1, 3
• For severe C. difficile colitis with significant systemic symptoms, consider vancomycin 500mg four times daily 3, 4

Step 3: Assess Response to Initial Therapy

• Evaluate response to oral steroids within 2 weeks 2
• For IV corticosteroids, assess response by day 3 2
• Failure criteria: >8 stools per day or 3-8 stools with CRP >45 mg/L on day 3 2

Step 4: Treatment for Steroid-Refractory Disease

• Consider rescue therapy with infliximab or cyclosporine for patients not responding to steroids by day 3 1, 2
• Both infliximab and cyclosporine have similar efficacy in steroid-refractory acute severe colitis 1

Special Considerations

Clostridium difficile Infection

• C. difficile infection in acute severe ulcerative colitis significantly increases colectomy risk 1
• Treat with oral vancomycin 125mg four times daily for 10 days 1, 3
• Do not escalate therapy or introduce rescue therapy with infliximab or calcineurin inhibitors in acute severe colitis with C. difficile 1

Cytomegalovirus (CMV) Infection

• Test for CMV in moderate to severe colitis, particularly in corticosteroid-refractory cases 1
• Risk factors for CMV: refractory disease, immunomodulator treatment, age over 30 years, corticosteroid use 1

Antibiotics in Acute Colitis

• Routine use of antibiotics is not recommended for acute colitis without evidence of infection 1
• The AGA suggests against adjunctive antibiotics for acute severe colitis without infections 1
• Meta-analysis showed no benefit of antibiotics over placebo for decreasing short-term risk of colectomy 1

Common Pitfalls to Avoid

• Inadequate initial dosing of prednisolone (<40mg daily) reduces effectiveness 2
• Delayed assessment of response to steroids can delay necessary treatment escalation 2
• Missing steroid-sparing strategies in steroid-dependent patients leads to prolonged steroid use 2
• Routine use of antibiotics without evidence of infection is not supported by evidence 1, 2
• Opioids should be avoided when possible due to risks of dependence, infection, and gut dysmotility 2

When to Consider Surgery

• Disease not responding to intensive medical therapy after 4-7 days of salvage therapy 1, 2
• Development of toxic megacolon (colonic dilatation ≥5.5 cm with systemic toxicity) 1
• Subtotal colectomy with ileostomy is the procedure of choice for emergency surgery 2

By following this evidence-based approach to acute colitis management, focusing on appropriate corticosteroid therapy, testing for and treating infections, and timely assessment of response, outcomes related to morbidity, mortality, and quality of life can be optimized.