What is the treatment for colitis, specifically ulcerative colitis?

Treatment of Ulcerative Colitis

The first-line treatment for mild to moderate ulcerative colitis is aminosalicylate therapy, specifically oral mesalamine ≥2.4 g/day combined with topical mesalamine enemas (≥1 g/day), which is more effective than either oral or topical therapy alone. 1, 2

Treatment Algorithm Based on Disease Severity and Location

Mild to Moderate Left-Sided Ulcerative Colitis

1. Initial therapy:

   • Aminosalicylate enema ≥1 g/day combined with oral mesalamine ≥2.4 g/day 1
   • Once-daily dosing is as effective as divided doses and may improve compliance 1
   • Topical mesalamine is more effective than topical steroids 1

2. If no response within 10-14 days or no complete relief after 40 days:

   • Add oral systemic corticosteroids 1
   • Consider budesonide MMX 9 mg/day (effective for left-sided disease) 1

Mild to Moderate Extensive Colitis

1. Initial therapy:

   • Aminosalicylate enema 1 g/day combined with oral mesalamine ≥2.4 g/day 1
   • Higher dose (4.8 g/day) may be more beneficial for moderate disease 1

2. If inadequate response to mesalamine:

   • Systemic corticosteroids 1

Severe Ulcerative Colitis (Acute Severe UC)

1. Hospitalization for intensive treatment 1, 2

2. Initial therapy:

   • IV corticosteroids (methylprednisolone 60 mg/day or hydrocortisone 100 mg four times daily) 2
   • Comprehensive supportive care including:
     • IV fluid and electrolyte replacement
     • Venous thromboembolism prophylaxis
     • Nutritional assessment and support
     • Blood transfusion if needed 2

3. Assessment at Day 3:

   • Poor response indicators: >8 stools/day or 3-8 stools with CRP >45 mg/L 2
   • If poor response, consider rescue therapy

4. Rescue therapy options:

   • Infliximab (5 mg/kg IV at 0,2, and 6 weeks, then every 8 weeks) 2, 3
   • Cyclosporine 2

5. Surgical consultation:

   • Obtain early in admission if no improvement within 48-72 hours 2

Maintenance Therapy

For Mild-Moderate Disease in Remission

• Continue oral mesalamine ≥2.4 g/day 1, 4
• Once-daily dosing is as effective as divided doses 1

For Moderate-Severe Disease or Steroid-Dependent Disease

1. Immunomodulators:

   • Azathioprine, mercaptopurine, or methotrexate 2
   • Warning: Combination of TNF blockers with azathioprine/6-mercaptopurine has been associated with hepatosplenic T-cell lymphoma, particularly in young males 3

2. Biologic agents for moderate-severe disease with inadequate response to conventional therapy:

   • Infliximab: 5 mg/kg IV at weeks 0,2, and 6, then every 8 weeks 3, 4
   • Other options: vedolizumab (anti-α4β7 integrin), ustekinumab (anti-IL-12/23), or JAK inhibitors like tofacitinib 4

Important Considerations and Monitoring

1. Before starting immunosuppressive therapy:

   • Test for tuberculosis and treat latent infection if present 3
   • Test for C. difficile and other pathogens 2

2. During therapy:

   • Monitor complete blood count within 4 weeks of starting immunomodulators and every 6-12 weeks thereafter 2
   • For patients on 5-ASA: monitor for potential adverse effects including worsening colitis, interstitial pneumonitis, and nephritis 5

3. Long-term monitoring:

   • Colonoscopy after 8-10 years to re-evaluate disease extent and screen for dysplasia 2, 4

Treatment Efficacy and Prognosis

• 5-ASA compounds induce remission in mild-moderate UC in 30-45% of patients 6
• Advanced therapies (biologics) have response rates of 30-60% in clinical trials 4
• Within 5 years of diagnosis, approximately 20% of patients are hospitalized and 7% require colectomy 4

Common Pitfalls to Avoid

1. Delaying escalation of therapy when patients fail to respond to initial treatment
2. Overlooking VTE prophylaxis in hospitalized patients with active disease 2
3. Failing to test for infections (particularly C. difficile) before starting immunosuppressive therapy 2
4. Discontinuing 5-ASA too early when starting biologics - combination therapy may be beneficial 6
5. Inadequate dosing of mesalamine - higher doses (4.8 g/day) may be needed for moderate disease 1