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

Treatment Options for Colitis

The treatment of colitis depends on disease type, location, and severity, with 5-aminosalicylates (5-ASA) as first-line therapy for mild to moderate ulcerative colitis, while corticosteroids, immunomodulators, and biologics are used for more severe disease or Crohn's disease. 1, 2

Ulcerative Colitis Treatment

Mild to Moderate Disease

Proctitis (Rectal Involvement)

• First-line: 1g 5-ASA suppository once daily (usually at night) 1
• If incomplete response: Add oral 5-ASA 2-3g daily 1
• If still inadequate: Add or switch to corticosteroid suppository (e.g., 5mg prednisolone) and optimize oral 5-ASA to 4-4.8g daily 1
• For refractory proctitis: Consider oral prednisolone, topical tacrolimus, JAK inhibitors, S1P agonists, or biologic therapy 1

Left-Sided or Extensive Colitis

• First-line: Oral 5-ASA ≥2.4g/day (once-daily dosing is as effective as divided doses) combined with topical 5-ASA enemas ≥1g/day 2
• If no response within 2-4 weeks: Initiate oral corticosteroids (prednisolone 40mg/day) 1
• Maintenance therapy: Continue with 5-ASA at ≥2g/day after achieving remission 2

Moderate to Severe Disease

• Initial therapy: Prednisolone 40mg/day orally combined with 5-ASA 1
• If no response within 2 weeks: Consider advanced therapy (biologics or small molecules) 1
• If hospitalized with acute severe colitis: IV methylprednisolone 60mg/day or hydrocortisone 100mg four times daily, plus IV fluids, electrolyte replacement, and thromboprophylaxis 2
• For steroid-refractory disease: Consider infliximab or cyclosporine 1

Crohn's Disease Treatment

• Mild disease: Topical steroids such as budesonide 3
• Moderate to severe disease: Corticosteroids for induction, followed by immunomodulators (azathioprine, 6-mercaptopurine) or biologics for maintenance 2
• Note: 5-ASA has limited effectiveness in Crohn's disease, though some evidence supports high-dose treatment 3, 4

Advanced Therapies

Biologics

• Anti-TNF agents (infliximab, adalimumab, golimumab): First-line biologics due to effectiveness, safety profile, and lower costs with biosimilars 2
• Anti-integrin (vedolizumab): Alternative for Crohn's disease 2
• IL-12/23 pathway blockers (ustekinumab): Used for Crohn's disease 2
• JAK inhibitors (tofacitinib): Used for ulcerative colitis 2

Immunomodulators

• Thiopurines (azathioprine, 6-mercaptopurine): Used for maintenance therapy, often after induction with corticosteroids 1
• Warning: Increased risk of lymphoma, particularly hepatosplenic T-cell lymphoma when combined with anti-TNF agents, especially in young males 5

Important Considerations

Monitoring

• Regular assessment of disease activity through clinical symptoms, inflammatory markers (CRP), and fecal calprotectin (>150 mg/g indicates active inflammation) 2
• Periodic endoscopic evaluation to assess mucosal healing 1

Safety Precautions

• Before immunosuppressive therapy: Test for infections including C. difficile and tuberculosis 2
• Thromboprophylaxis: Use low-molecular-weight heparin for hospitalized patients due to high thrombotic risk 2
• Avoid: Anticholinergics, anti-diarrheals, NSAIDs, and opioids in acute colitis as they can worsen the condition 2

Special Populations

• Pregnancy: Most IBD medications are safe; active disease poses greater risk than treatment 2
• Malignancy risk: Patients on immunosuppressants have increased risk of lymphoma and skin cancers; regular skin examinations recommended 6, 5

Treatment Goals

The treatment goal has shifted from achieving clinical response to achieving remission, which should be assessed biochemically, endoscopically, and histologically to prevent long-term disease complications 1. Maintenance therapy should continue with the agent successful in induction, except corticosteroids which are not recommended for long-term use 1.

Common Pitfalls to Avoid

• Delaying thromboprophylaxis in hospitalized patients
• Missing C. difficile infection before starting immunosuppression
• Inadequate potassium replacement in acute colitis
• Prolonged ineffective steroid therapy
• Using antimotility agents in acute colitis (risk of toxic megacolon)
• Overlooking the increased risk of lymphoma with combination therapy of thiopurines and anti-TNF agents