What are the treatment options for microscopic colitis?

Treatment Options for Microscopic Colitis

Budesonide is the first-line treatment for both induction and maintenance therapy in patients with symptomatic microscopic colitis due to its proven efficacy in reducing symptoms and improving quality of life. 1

First-Line Treatment Options

Induction Therapy

• Budesonide: Strongly recommended as first-line therapy for induction of clinical remission with moderate quality evidence 1
  • Demonstrated superior efficacy compared to mesalamine (high quality evidence) 1
  • Standard dosing is 9 mg daily for 6-8 weeks 2

Alternative First-Line Options (when budesonide is not feasible)

• Mesalamine: Conditionally recommended with moderate quality evidence 1
• Bismuth salicylate: Conditionally recommended with low quality evidence 1
• Prednisolone/Prednisone: Conditionally recommended with very low quality evidence 1
• Antidiarrheals (e.g., loperamide): Appropriate for patients with mild symptoms 2

Maintenance Therapy

• Budesonide: Strongly recommended for patients who experience symptom recurrence after induction therapy 1
  • Maintenance dosing typically starts at 6 mg daily and can be tapered to lowest effective dose 1
  • Reduces risk of clinical relapse by 66% (relative risk 0.34,95% CI 0.19-0.6) 1
  • Consider 6-12 months of maintenance therapy before attempting discontinuation 1
  • Monitor for potential bone loss with prolonged use; consider osteoporosis prevention and screening 1

Treatment Considerations

Medication Discontinuation

• Identify and discontinue potential triggering medications when possible 2:
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) 1
  • Proton pump inhibitors (PPIs) 1
  • Selective serotonin reuptake inhibitors (SSRIs) 1
  • Statins 2

Treatment Algorithm

1. Mild symptoms: Start with antidiarrheals like loperamide 2
2. Moderate to severe symptoms: Initiate budesonide 9 mg daily 2
3. Recurrent symptoms: Consider maintenance budesonide at lowest effective dose 1
4. Refractory disease: Limited evidence suggests immunosuppressants (azathioprine) or anti-TNF agents may be beneficial 1

Not Recommended Treatments

• Combination therapy with cholestyramine and mesalamine: Not superior to mesalamine alone (conditional recommendation, low quality evidence) 1
• Boswellia serrata: Not recommended (conditional recommendation, low quality evidence) 1
• Probiotics: Not recommended (conditional recommendation, low quality evidence) 1

Special Considerations

• Up to one-third of patients may not require maintenance therapy after successful induction 1
• For patients with refractory disease, consider:
  • Re-evaluation for other causes of diarrhea, including celiac disease 1
  • Potential functional bowel disorders or post-inflammatory symptoms 1
  • Immunomodulators for rare severe cases 2
• The goal of therapy is to relieve symptoms and improve quality of life while minimizing drug-related adverse effects 1

Emerging Therapies

• Biologic and small molecule treatments may be effective in budesonide-refractory disease, though more research is needed 3