What is the treatment for colitis with leukocytosis (high White Blood Cell (WBC) count)?

From the Guidelines

Treatment of colitis with elevated white blood cell count (WBC) should prioritize corticosteroids, such as prednisone (starting at 1-2 mg/kg/d) or equivalent, until symptoms improve, and then start taper over 4-6 weeks, as recommended by the most recent guidelines 1. When managing colitis with leukocytosis, it's essential to consider the severity of the disease and the potential for complications.

Key Considerations

• The presence of an elevated WBC count indicates active inflammation or infection, which guides treatment intensity.
• First-line treatments include anti-inflammatory medications such as mesalamine or corticosteroids like prednisone for moderate to severe cases.
• Antibiotics may be necessary if infection is suspected, with metronidazole or ciprofloxacin commonly prescribed.
• Immunomodulators like azathioprine or biologics such as infliximab may be required for more severe or refractory cases.

Treatment Approach

• For moderate to severe cases, corticosteroids like prednisone (starting at 1-2 mg/kg/d) or equivalent should be administered until symptoms improve, and then start taper over 4-6 weeks 1.
• Consider early introduction of infliximab or vedolizumab in addition to steroids in patients with high-risk endoscopic features on initial endoscopy examination or inadequate response to steroids.
• Supportive care includes intravenous fluids for dehydration, electrolyte replacement, and sometimes bowel rest.

Monitoring and Follow-up

• Regular monitoring of symptoms, WBC counts, and inflammatory markers is essential to assess treatment effectiveness.
• Patients should maintain adequate hydration, follow a low-residue diet during flares, avoid NSAIDs and trigger foods, and seek immediate medical attention for severe symptoms like high fever, severe pain, or significant bleeding. The most recent guidelines from 2021 1 provide the best approach for managing colitis with elevated WBC, prioritizing corticosteroids and considering biologics for severe or refractory cases.

From the FDA Drug Label

In addition, a greater proportion of patients in infliximab groups demonstrated sustained response and sustained remission than in the placebo groups The improvement with infliximab was consistent across all Mayo subscores through Week 54 Clinical response at Week 8 was defined as a decrease from baseline in the Mayo score by ≥ 30% and ≥ 3 points, including a decrease in the rectal bleeding subscore by ≥ 1 points or achievement of a rectal bleeding subscore of 0 or 1.

The treatment for colitis with leukocytosis (high White Blood Cell (WBC) count) is Infliximab (IV).

• Key points:
  • Infliximab has been shown to induce and maintain clinical remission in patients with moderately to severely active ulcerative colitis.
  • The improvement with infliximab was consistent across all Mayo subscores.
  • Clinical response and remission were assessed using the Mayo score and the Pediatric Ulcerative Colitis Activity Index (PUCAI) score. 2

From the Research

Treatment for Colitis with Leukocytosis

The treatment for colitis with leukocytosis (high White Blood Cell (WBC) count) involves a multidisciplinary approach, including medical and surgical options.

• The first-line treatment for ulcerative colitis (UC) typically involves intravenous corticosteroids to control inflammation 3, 4, 5, 6.
• Approximately 20-30% of patients with UC may not respond to initial intravenous corticosteroid treatment and may require second-line medical rescue therapy, such as infliximab or cyclosporine 3, 4, 5.
• Early surgical consultation is crucial in cases where medical therapy is ineffective, and colectomy may be necessary as a salvage option 3, 4, 5.
• Patients with acute severe ulcerative colitis (ASUC) are at high risk for thromboembolic complications, and DVT prophylaxis should be started as soon as possible 5.
• A step-up algorithm for managing ASUC involves assessing response to steroids at day 3 of admission and considering alternative medical therapy or surgery for partial or non-responders 6.

Medical Therapy

• First-line therapies for inflammatory bowel disease (IBD) include 5-aminosalicylates, budesonide, systemic steroids, azathioprine, 6-mercaptopurine, methotrexate, infliximab, adalimumab, and certolizumab pegol 7.
• Medical rescue therapies, such as intravenous cyclosporin and infliximab, may be considered for patients who do not respond to initial treatment 4, 6.

Surgical Options

• Colectomy may be necessary as a salvage option for patients with complications such as toxic megacolon, perforation, or hemorrhage, or for those who do not respond to medical therapy 3, 4, 5.
• Early surgical consultation is essential in the management of hospitalized UC patients to discuss the possibility of a staged proctocolectomy as one of the therapeutic options 4.