What are the management options for microscopic colitis?

Microscopic Colitis Workup and Management

Budesonide is strongly recommended as the first-line treatment for microscopic colitis at a dose of 9 mg daily for 8 weeks, as patients are more than twice as likely to achieve clinical remission compared to no treatment. 1

Diagnostic Workup

Colonoscopy with Biopsies

• Obtain biopsies from multiple segments of the colon during colonoscopy (strong recommendation) 1
• The colon typically appears normal endoscopically, making histologic evaluation essential for diagnosis 2
• Biopsies help differentiate between subtypes: lymphocytic colitis and collagenous colitis 3

Medication Review and Risk Factor Assessment

• Identify and discontinue medications associated with microscopic colitis 1:

  • Proton pump inhibitors (PPIs)
  • Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Selective serotonin reuptake inhibitors (SSRIs)
  • Statins

• Assess modifiable risk factors 1:

  • Cigarette smoking
  • Alcohol consumption

Associated Conditions Screening

• Screen for celiac disease (present in 5-7% of microscopic colitis patients) 1
• Evaluate for bile acid diarrhea (present in 41% of collagenous colitis and 29% of lymphocytic colitis) 1
• Consider other autoimmune diseases which are common comorbidities 2

Management Algorithm

First-Line Treatment

• Budesonide 9 mg daily for 8 weeks (strong recommendation, high-quality evidence) 1
  • Most effective for both clinical symptom improvement and histological inflammation reduction
  • Patients are 2.52 times more likely to achieve clinical remission compared to no treatment
  • Convenient once-daily dosing with favorable risk/benefit profile

Alternative Treatments (If Budesonide Not Feasible)

1. Mesalamine (conditional recommendation, moderate quality evidence) 1

   • Second-line treatment, though less effective than budesonide

2. Bismuth salicylate (conditional recommendation, low quality evidence) 1

   • Third-line treatment option

3. Prednisolone/prednisone (conditional recommendation, very low quality evidence) 1

   • Fourth-line treatment option

4. Antidiarrheals such as loperamide for mild symptoms 2

5. Bile acid sequestrants (e.g., cholestyramine) for patients with bile acid diarrhea 1, 4

Maintenance Therapy

• For recurrent symptoms, consider low-dose budesonide maintenance therapy 1, 2
• Monitor bone health in patients on long-term budesonide therapy 1
• Consider discontinuation of budesonide after 6-12 months 1
• For steroid-dependent cases, consider immunomodulators or biologics in refractory cases 3, 4

Special Considerations

Disease Severity Assessment

• Tailor treatment based on symptom severity 2:
  • Mild symptoms: antidiarrheals like loperamide
  • Moderate-severe disease: budesonide for induction of remission
  • Refractory cases: consider immunomodulators

Common Pitfalls to Avoid

• Failing to obtain biopsies from multiple colon segments 1
• Overlooking associated conditions like celiac disease 1
• Neglecting bone health monitoring in patients on long-term budesonide 1
• Missing incomplete forms of microscopic colitis which can be overlooked in routine clinical settings 3
• Continuing medications that may trigger or worsen microscopic colitis 1, 4

High-Risk Populations

• Elderly patients (mean age at presentation around 60 years) 1
• Female patients (77% of collagenous colitis and 68% of lymphocytic colitis cases) 1
• Patients with other autoimmune diseases 2
• Patients receiving checkpoint inhibitors for malignancies may require more aggressive therapeutic approach with early introduction of biologics 3