What is the treatment approach for inflammatory colitis?

Treatment Approach for Inflammatory Colitis

The first-line treatment for inflammatory colitis includes oral and/or rectal mesalamine (5-ASA) at 2-4g/day for mild to moderate disease, with oral corticosteroids (prednisolone 40mg daily) recommended for patients who fail to respond to mesalamine or have more severe disease. 1

Diagnostic Workup

Before initiating treatment, a proper diagnostic workup should include:

• Stool testing for C. difficile infection and entero-invasive bacteria
• Complete blood count, inflammatory markers (CRP or ESR), electrolytes and liver function tests
• Plain abdominal radiograph to exclude colonic dilatation (≥5.5 cm)
• Flexible sigmoidoscopy to confirm diagnosis and assess disease severity
• Colonic biopsies in moderate to severe cases to check for cytomegalovirus (CMV)

Treatment Algorithm Based on Disease Severity

Mild to Moderate Disease

1. First-line therapy: Mesalamine (5-ASA) 2-4g/day

   • Combination of oral (2-4g daily) and topical (1g daily) mesalamine is more effective than either alone 1
   • Topical formulation should match disease extent

2. For patients who fail to respond within 4-8 weeks:

   • Oral prednisolone 40mg daily with gradual taper over 8 weeks 1
   • Alternative: Budesonide MMX 9mg daily (fewer systemic side effects) 1

Moderate to Severe Disease

1. Initial therapy: Oral prednisolone 40mg daily or IV methylprednisolone 60mg/day 1

2. For steroid-refractory disease (assess by day 3):

   • Rescue therapy with infliximab or cyclosporine 1
   • Infliximab dosing: 5 mg/kg IV at weeks 0,2, and 6, followed by maintenance dosing every 8 weeks 2

3. For steroid-dependent disease:

   • Immunomodulators: azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.5 mg/kg/day) 1

Acute Severe Colitis

1. IV corticosteroids: Methylprednisolone 60 mg/day or hydrocortisone 100 mg four times daily 1

2. If C. difficile positive: Oral vancomycin 125mg four times daily for 10 days 1

3. If no response by day 3: Consider rescue therapy with infliximab or cyclosporine 1

4. If no response after 4-7 days of salvage therapy: Consider surgical intervention 1

Special Considerations

Antibiotic Use

• Routine use of antibiotics is not recommended without evidence of infection 1
• Meta-analyses show no benefit of antibiotics over placebo for decreasing short-term risk of colectomy 1

Surgical Management

• Indications for surgery:

  • Disease not responding to intensive medical therapy
  • Development of toxic megacolon (colonic dilatation ≥5.5 cm with systemic toxicity)
  • C. difficile infection in acute severe ulcerative colitis significantly increases colectomy risk

• Procedure of choice in acute fulminant colitis: Subtotal colectomy with ileostomy 1

Monitoring and Follow-up

• Assess response to oral steroids within 2 weeks
• For IV corticosteroids, assess response by day 3
• Formal assessment criteria on day 3: >8 stools per day or 3-8 stools with CRP >45 mg/L 1
• Monitor stool frequency, presence of blood, and inflammatory markers (CRP)
• Regular surveillance colonoscopies after 8-10 years to re-evaluate disease extent 1

Common Pitfalls to Avoid

1. Inadequate initial dosing of prednisolone (<40 mg daily) for moderate to severe disease 1
2. Delayed assessment of response to steroids, which can delay necessary treatment escalation 1
3. Missing steroid-sparing strategies in steroid-dependent patients 1
4. Failure to recognize infectious causes of colitis
5. Delaying surgical consultation in severe cases
6. Routine use of antibiotics without evidence of infection
7. Use of opioids, which should be avoided due to risks of dependence, infection, narcotic bowel syndrome, and gut dysmotility 1
8. Overprescription of mesalamine for Crohn's disease (it's more effective for ulcerative colitis) 3
9. Delayed introduction of biologic therapy in appropriate candidates 3