What are the management options for microscopic colitis?

Microscopic Colitis Management

Budesonide at 9 mg daily for 8 weeks is the first-line treatment for symptomatic microscopic colitis, with patients being 2.52 times more likely to achieve clinical remission compared to no treatment. 1

Diagnostic Workup

• Obtain biopsies from multiple segments of the colon during colonoscopy (normal-appearing mucosa)
• Screen for associated conditions:
  • Celiac disease (present in 5-7% of microscopic colitis patients)
  • Bile acid diarrhea (present in 41% of collagenous colitis and 29% of lymphocytic colitis)
• Review medications that may cause or exacerbate microscopic colitis:
  • NSAIDs
  • Proton pump inhibitors
  • SSRIs
  • Statins
• Assess modifiable risk factors:
  • Cigarette smoking
  • Alcohol consumption

Treatment Algorithm

First-Line Treatment

• Budesonide 9 mg daily for 8 weeks
  • High-quality evidence supports its effectiveness
  • Superior efficacy with patients 2.52 times more likely to achieve remission
  • Improves both clinical symptoms and histological inflammation
  • Favorable risk/benefit profile with convenient once-daily dosing 1

Second-Line Options (if budesonide not feasible)

1. Mesalamine

   • Conditional recommendation based on moderate quality evidence
   • Less effective than budesonide 1

2. Bismuth salicylate

   • Conditional recommendation based on low quality evidence
   • Significant pill burden (8-9 tablets divided 3 times daily)
   • Consider for patients with contraindications to corticosteroids or cost concerns 2

3. Prednisolone/Prednisone

   • Conditional recommendation based on very low quality evidence
   • Consider for patients with refractory symptoms after other treatments
   • Risk of adverse events is significant with systemic corticosteroids 2

4. Symptomatic treatment with loperamide

   • Can be used as adjunct therapy for immediate symptomatic relief 3

For Refractory Disease

• Consider:
  • Cholestyramine (especially if bile acid diarrhea is present)
  • Immunomodulators (azathioprine, methotrexate)
  • Anti-TNF-α inhibitors 3

Maintenance Therapy

• Consider low-dose budesonide for maintenance in patients with recurrent symptoms
• Monitor bone health in patients on long-term budesonide therapy
• Consider discontinuation of budesonide after 6-12 months 1

Important Considerations

Medication Management

• Discontinue medications associated with microscopic colitis when possible:
  • NSAIDs, PPIs, SSRIs, statins 1, 3

Not Recommended

• Combination therapy with cholestyramine and mesalamine (no incremental benefit over mesalamine alone) 2
• Boswellia serrata (insufficient evidence of benefit) 2
• Probiotics (insufficient evidence of benefit) 2

Monitoring

• Assess response to treatment based on reduction in diarrhea frequency and improved stool consistency
• For patients on long-term budesonide: monitor for bone loss and other corticosteroid-related side effects 1

Common Pitfalls to Avoid

• Failing to obtain biopsies from multiple colon segments during diagnosis
• Overlooking associated conditions like celiac disease or bile acid diarrhea
• Neglecting bone health monitoring in patients on long-term budesonide
• Continuing medications that may trigger or worsen microscopic colitis
• Inadequate follow-up of patients with recurrent or refractory disease 1