What are the treatment options for managing colitis, specifically ulcerative colitis or Crohn's disease?

Treatment Options for Managing Colitis

For mild to moderate ulcerative colitis, initial treatment should consist of aminosalicylates (5-ASA) with a combination of oral mesalamine ≥2.4 g/day and topical mesalamine enemas ≥1 g/day, as this approach is more effective than either oral or topical therapy alone. 1

Treatment Algorithm Based on Disease Severity and Location

Mild to Moderate Ulcerative Colitis

• Left-sided disease:

  • First-line: Combination of oral mesalamine ≥2.4 g/day plus mesalamine enema ≥1 g/day 1
  • Once-daily dosing is as effective as divided doses 1
  • If no response within 10-14 days or incomplete relief after 40 days: Add oral corticosteroids 1
  • For patients inadequately controlled with 5-ASA: Consider budesonide MMX 9 mg/day (particularly effective for left-sided disease) 1

• Extensive disease:

  • First-line: Combination of oral mesalamine ≥2.4 g/day plus mesalamine enema 1 g/day 1
  • For moderate to severe activity or non-responders to mesalamine: Systemic corticosteroids 1

Severe Ulcerative Colitis

• Hospitalization for intensive treatment 1
• IV corticosteroids (methylprednisolone 60 mg/day or hydrocortisone 100 mg four times daily) 2
• IV fluid and electrolyte replacement, with special attention to potassium (≥60 mmol/day) 2
• Thromboprophylaxis with low-molecular-weight heparin 2
• If no response to IV steroids after 3-5 days: Consider rescue therapy with:
  • Infliximab (5 mg/kg at 0,2, and 6 weeks, then every 8 weeks) 2, 3
  • Cyclosporine 2

Crohn's Disease

• Mild to moderate:

  • Budesonide (topical steroids) 4
  • Conventional immunosuppressive therapies (azathioprine, 6-mercaptopurine, methotrexate) 2
  • For fistulizing disease: Infliximab 5 mg/kg at 0,2, and 6 weeks, then every 8 weeks 3

• Moderate to severe:

  • Infliximab 5 mg/kg at 0,2, and 6 weeks, then every 8 weeks (for adults and pediatric patients ≥6 years) 3
  • For patients who lose response: Consider increasing to 10 mg/kg 3
  • If no response by week 14: Consider discontinuing infliximab 3

Maintenance Therapy

Ulcerative Colitis

• Aminosalicylates are effective for maintaining remission 5
• Oral mesalamine ≥2.4 g/day, once-daily dosing is effective 1
• Rectal 5-ASA is useful for maintaining remission in distal UC 5

Crohn's Disease

• Aminosalicylates at doses ≥2 g/day may help maintain remission 5
• Azathioprine and 6-mercaptopurine are beneficial for long-term steroid-sparing therapy 5
• Infliximab maintenance at 5 mg/kg every 8 weeks 3

Important Considerations and Precautions

Medication Safety

• Infliximab:

  • Screen for latent tuberculosis before starting therapy 3
  • Monitor for invasive fungal infections, bacterial and viral infections 3
  • Risk of lymphoma and other malignancies, particularly hepatosplenic T-cell lymphoma in young males 3

• Azathioprine:

  • Increased risk of malignancy, particularly skin cancer and lymphoma 6
  • Risk of severe bone marrow suppression requiring regular blood count monitoring 6
  • Consider TPMT and NUDT15 deficiency testing before initiating therapy 6
  • Increased risk of serious infections 6

Common Pitfalls to Avoid

• Delaying thromboprophylaxis in hospitalized patients with acute colitis 2
• Missing C. difficile infection (always test before starting immunosuppressive therapy) 2
• Using antimotility agents, anticholinergics, NSAIDs, or opioids in acute colitis (can precipitate toxic megacolon) 2
• Inadequate potassium replacement (can worsen colonic dilatation) 2
• Prolonged ineffective steroid therapy without escalation to rescue therapy 2
• Underdosing aminosalicylates (doses <2 g/day show little benefit in Crohn's disease) 5

Special Populations

• Pediatric patients (≥6 years): Similar approach to adults with dose adjustments 2
• Pregnancy: Most IBD medications are safe; active disease poses greater risk than treatment 2

The treatment of colitis requires a systematic approach based on disease type, severity, and location. Early identification of non-responders and timely escalation of therapy are crucial to prevent complications and improve outcomes.