What are the treatment options for managing colitis?

Treatment Options for Managing Colitis

The optimal management of colitis requires a stepwise approach starting with 5-aminosalicylates (5-ASA) for mild to moderate disease, progressing to corticosteroids for non-responders, and advancing to immunomodulators or biologics for moderate to severe disease. 1, 2

First-Line Therapy for Mild to Moderate Colitis

• Oral 5-ASA (mesalamine): 2-4g/day is the first-line therapy 2

  • Minimum effective dose is 2g/day
  • Often combined with topical 5-ASA for distal disease
  • Goal is complete remission (both symptomatic and endoscopic) without corticosteroids 1

• Topical therapy: Rectal 5-ASA formulations for distal disease 1

  • Particularly effective for left-sided colitis
  • Can be used in combination with oral therapy for enhanced efficacy

Second-Line Therapy for Inadequate Response to 5-ASA

• Oral corticosteroids: Prednisolone 40mg daily with gradual taper over 6-8 weeks 2

  • Highly effective for inducing remission
  • Not appropriate for maintenance therapy due to significant adverse effects
  • Short-term adverse effects: acne, edema, sleep disturbances, mood changes, glucose intolerance
  • Long-term adverse effects: osteoporosis, adrenal suppression, increased infection risk, hypertension

• Budesonide MMX: Topically-acting oral corticosteroid 2

  • Alternative for patients wishing to avoid systemic corticosteroid effects
  • Lower systemic bioavailability than conventional corticosteroids

Therapy for Moderate to Severe Colitis

• Initial approach: Oral corticosteroid therapy (prednisolone 40mg daily) 1, 2

  • For patients who achieve remission, transition to maintenance therapy

• Maintenance options after corticosteroid-induced remission 1:

  1. 5-ASA (for milder disease)
  2. Thiopurines (azathioprine 1.5-2.5 mg/kg/day or mercaptopurine 0.75-1.5 mg/kg/day)
  3. Anti-TNF therapy (with or without thiopurine or methotrexate)
  4. Vedolizumab

Management of Corticosteroid-Resistant/Dependent Colitis

• Anti-TNF therapy: Infliximab is FDA-approved for moderate to severe ulcerative colitis 1, 3

  • Dosing: 5 mg/kg at weeks 0,2, and 6, then every 8 weeks 3
  • Monitor for serious infections, including tuberculosis (requires TB testing before initiation)
  • Risk of malignancies, particularly lymphoma, especially when combined with thiopurines 3

• Vedolizumab: Alternative biologic option for corticosteroid-resistant/dependent disease 1, 2

  • Gut-selective mechanism may offer improved safety profile

Management of Hospitalized Patients with Severe Colitis

• Intravenous corticosteroids: Methylprednisolone 60mg/day or hydrocortisone 100mg four times daily 2, 4

• Supportive care 2, 4:

  • Intravenous fluid resuscitation
  • Electrolyte monitoring and replacement
  • Venous thromboembolism prophylaxis
  • NPO status if severe symptoms or risk of perforation

• Rescue therapy for non-responders to IV steroids after 2-3 days 2:

  • Infliximab or vedolizumab (preferably within 2 weeks of symptom onset)
  • Early surgical consultation is essential

Assessment of Treatment Response

• Formal assessment on day 3 of therapy for hospitalized patients 2

  • Failure criteria: >8 stools per day or 3-8 stools with CRP >45 mg/L

• Response indicators 2:

  • Improvement in clinical symptoms within 48-72 hours
  • Reduction in stool frequency
  • Normalization of vital signs
  • Decreasing inflammatory markers

Surgical Considerations

• Indications for emergency surgery 2:

  • Free perforation
  • Massive hemorrhage
  • Generalized peritonitis
  • Toxic megacolon not responding to medical therapy
  • Clinical deterioration despite appropriate medical management

• Procedure of choice for severe ulcerative colitis: subtotal colectomy with ileostomy 2

Common Pitfalls to Avoid

• Delayed surgical consultation in severe cases 2
• Inadequate initial resuscitation leading to complications 2
• Missing Clostridioides difficile infection (always test for C. difficile in antibiotic-associated colitis) 2
• Overlooking VTE prophylaxis (essential due to high thrombotic risk in colitis) 2
• Inappropriate use of antimotility agents (can worsen toxic megacolon) 2
• Delayed escalation of therapy in non-responders 2
• Prolonged corticosteroid use without steroid-sparing strategies 2
• Routine use of opioids (risks of dependence, infection, narcotic bowel syndrome, and gut dysmotility) 2

The management of colitis requires timely assessments of response and remission to ensure optimal outcomes, with the ultimate goal being complete remission without corticosteroid therapy 1.