What are the treatment options for colitis?

Treatment Options for Colitis

The first-line treatment for colitis depends on the type, location, and severity of disease, with oral mesalamine 2-4g/day combined with mesalamine enemas 4g daily being the standard initial therapy for mild to moderate ulcerative colitis. 1

Classification and Initial Assessment

• Disease type: Determine if inflammatory bowel disease (ulcerative colitis, Crohn's disease) or other form (infectious, immune checkpoint inhibitor-induced, etc.)
• Disease extent: Assess endoscopic extent (proctitis, left-sided, extensive/pancolitis)
• Disease severity: Categorize as mild, moderate, or severe based on symptoms and laboratory findings
• Rule out infections: Exclude infectious causes before starting treatment 2, 1

Treatment Algorithm by Disease Type and Severity

Mild to Moderate Ulcerative Colitis

1. First-line therapy:

   • Oral mesalamine 2-4g daily (higher doses for moderate disease)
   • PLUS mesalamine enemas 4g daily for distal disease 1
   • Once-daily dosing is as effective as multiple daily doses
   • Continue for 4-8 weeks for induction of remission

2. If inadequate response after 2-4 weeks:

   • Increase oral mesalamine to maximum dose (4.8g/day)
   • Ensure proper administration and adherence to topical therapy 1

3. For refractory disease:

   • Add rectal corticosteroids (budesonide foam or hydrocortisone enemas)
   • Consider oral prednisone 40mg daily with 6-8 week taper 1

Moderate to Severe Ulcerative Colitis

1. Initial therapy:

   • Oral corticosteroids (prednisolone 40mg daily) for rapid induction of remission 1
   • OR consider biologic therapy (infliximab 5mg/kg at weeks 0,2, and 6, then every 8 weeks) 3

2. For steroid-refractory disease:

   • Infliximab 5mg/kg IV at weeks 0,2, and 6, then every 8 weeks 3
   • Alternative biologics or immunomodulators may be considered

Severe or Fulminant Colitis

1. Hospital admission with:

   • IV corticosteroids (methylprednisolone 60mg/day or hydrocortisone 100mg four times daily)
   • IV fluid resuscitation and electrolyte replacement
   • VTE prophylaxis
   • NPO status if severe symptoms or perforation risk 1

2. If no improvement within 3-5 days:

   • Consider rescue therapy with infliximab or cyclosporine
   • Early surgical consultation 1

3. Indications for emergency surgery:

   • Free perforation
   • Massive hemorrhage
   • Toxic megacolon unresponsive to medical therapy
   • Clinical deterioration despite appropriate treatment 1

Immune Checkpoint Inhibitor (ICI) Colitis

1. Diagnosis:

   • Exclude infectious causes
   • Consider stool inflammatory markers (lactoferrin, calprotectin)
   • Endoscopic confirmation before high-dose steroids 2

2. Treatment:

   • High-dose systemic glucocorticoids (0.5-2 mg/kg prednisone equivalent daily)
   • 4-6 week taper
   • For steroid-refractory cases: infliximab or vedolizumab 2

3. For microscopic colitis pattern:

   • Consider budesonide 2

Infectious Colitis

1. C. difficile colitis:

   • Vancomycin 125mg orally four times daily 1

2. Other bacterial colitis:

   • Targeted antibiotics based on culture results and susceptibility
   • Supportive care 4

Maintenance Therapy

• After induction of remission, transition to maintenance therapy:
  • Oral mesalamine (minimum 2g/day) for mild-moderate disease 1
  • Consider immunomodulators or biologics for moderate-severe or steroid-dependent disease 1, 3

Monitoring Response

• Assess clinical response within 3-7 days of initiating therapy
• Monitor stool frequency, bleeding, abdominal pain, and vital signs
• Check laboratory markers (WBC, CRP, albumin)
• Perform endoscopic assessment after 4-8 weeks to confirm mucosal healing 1

Common Pitfalls to Avoid

• Inadequate initial dosing: Using less than 2g/day of oral mesalamine is associated with higher relapse rates 1
• Missing infectious causes: Always test for C. difficile and other pathogens before starting immunosuppressive therapy 2, 1
• Delayed escalation: Assess response by day 3 and escalate if inadequate improvement 1
• Prolonged steroid use: Implement steroid-sparing strategies early 1
• Delayed surgical consultation: Early surgical consultation is essential for severe colitis 1
• Inappropriate use of antimotility agents: Can worsen toxic megacolon 1
• Overlooking VTE prophylaxis: Essential in all colitis patients due to high thrombotic risk 1

By following this structured approach based on disease type, location, and severity, most patients with colitis can achieve remission with appropriate therapy.