What is the treatment for colitis?

Treatment for Colitis

The treatment for colitis should be tailored based on disease extent, severity, and type, with aminosalicylates (5-ASA) as first-line therapy for mild to moderate ulcerative colitis, combined with topical therapy for distal disease, and systemic corticosteroids for more severe disease or those who fail to respond to 5-ASA therapy. 1

Treatment Based on Disease Extent and Severity

Distal Ulcerative Colitis (Proctitis and Left-sided Colitis)

• For mild to moderate distal UC, topical mesalazine 1g daily combined with oral mesalazine ≥2.4g daily is the most effective first-line therapy 1
• Topical mesalazine is more effective than topical corticosteroids and should be the preferred topical agent 1
• Once-daily dosing with mesalazine is as effective as divided doses 1
• Topical formulation should be selected based on disease extent: suppositories for disease limited to rectum, foam or liquid enemas for more proximal disease 1
• Patients who fail to improve on combination therapy should be treated with oral prednisolone 40mg daily 1

Extensive Ulcerative Colitis

• Mild to moderate extensive UC should be treated with oral mesalazine ≥2.4g daily combined with topical mesalazine enemas 1g daily 1
• Systemic corticosteroids (prednisolone 40mg daily) are appropriate for moderate to severe disease or for patients with mild disease who don't respond to mesalazine 1
• Prednisolone should be tapered gradually over approximately 8 weeks according to patient response 1
• Severe extensive colitis requires hospital admission for intensive treatment 1

Severe Ulcerative Colitis

• Requires hospital admission and joint management by gastroenterologist and colorectal surgeon 1
• Treatment approach includes:
  • Daily physical examination to evaluate abdominal tenderness 1
  • Regular monitoring of vital signs, stool frequency, and laboratory parameters 1
  • Intravenous fluid and electrolyte replacement 1
  • Subcutaneous heparin to reduce thromboembolism risk 1
  • Nutritional support if malnourished 1

Medication Options

Aminosalicylates (5-ASA)

• First-line therapy for mild to moderate UC 1, 2
• Options include mesalazine (2-4g daily), balsalazide (6.75g daily), olsalazine (1.5-3g daily) 1
• Combination of oral and topical 5-ASA is more effective than either alone 1, 2
• Sulfasalazine (2-4g daily) has higher incidence of side effects compared to newer 5-ASA drugs 1

Corticosteroids

• Indicated for moderate to severe UC or when 5-ASA therapy fails 1
• Oral prednisolone 40mg daily is standard dosing 1
• Budesonide MMX can be considered for left-sided disease in patients inadequately controlled with 5-ASA 1
• Not recommended for long-term maintenance therapy 1

Immunomodulators

• Azathioprine (1.5-2.5mg/kg/day) or mercaptopurine (0.75-1.5mg/kg/day) are indicated for steroid-dependent disease 1
• Can be used for maintenance therapy 1

Biologics

• Anti-TNF agents (infliximab, adalimumab, golimumab) are indicated for moderate to severe UC that is refractory to conventional therapy 3, 4, 5
• Infliximab dosing: 5mg/kg at weeks 0,2, and 6, then every 8 weeks 3
• Adalimumab is approved for moderate to severely active UC 4

Maintenance Therapy

• Lifelong maintenance therapy is generally recommended, especially for left-sided or extensive disease 1
• 5-ASA compounds are effective and safe for maintenance therapy 2, 6
• Immunomodulators can be used for maintenance in steroid-dependent patients 1
• Biologics should be continued in patients who respond to induction therapy 3, 4

Special Considerations

• Proximal constipation should be treated with stool bulking agents or laxatives 1
• There is some evidence for probiotics (particularly VSL#3) as adjunctive therapy 1
• Fecal transplantation shows promise but requires further research to define optimal protocols 1
• Recent evidence suggests combination of mesalazine with corticosteroids does not provide additional benefit over corticosteroids alone in acute severe UC 7

Treatment Goals

• The primary goals are to induce and maintain remission, achieve mucosal healing, avoid surgical intervention, and decrease cancer risk 8
• Treatment should aim for complete remission, assessed biochemically, endoscopically, and histologically 1