What is the treatment and management approach for a 75-year-old man with diffuse active colitis in the sigmoid colon and transverse colon, diagnosed via mucosal biopsy?

From the Guidelines

For diffuse active colitis in the sigmoid and transverse colon of a 75-year-old man, I recommend starting with 5-aminosalicylic acid (5-ASA) therapy such as mesalamine 4.8g daily orally, as it has been shown to be more effective than 2.4g daily in achieving remission and mucosal healing 1. This should be combined with topical therapy using mesalamine enemas 4g daily or suppositories 1g daily for 2-4 weeks. If symptoms are moderate to severe, add prednisone 40mg daily with a gradual taper over 8-12 weeks. For maintenance, continue oral mesalamine at 2-2.4g daily long-term. The patient should undergo colonoscopy with biopsies to determine the extent of disease and rule out cytomegalovirus infection. Blood tests including complete blood count, liver function tests, and C-reactive protein should be monitored regularly. If the patient doesn't respond to initial therapy within 2-3 weeks, consider adding immunomodulators like azathioprine 2-2.5mg/kg/day or biologics such as infliximab (5mg/kg at weeks 0,2, and 6, then every 8 weeks) 1. These medications work by reducing inflammation through different mechanisms - 5-ASA compounds act locally to decrease inflammatory mediators, corticosteroids provide broad anti-inflammatory effects, and immunomodulators suppress the abnormal immune response driving the colitis. It is also important to consider the role of biomarkers in monitoring disease activity and adjusting treatment, as suggested by the AGA clinical practice guideline on the role of biomarkers for the management of ulcerative colitis 1. Some key points to consider in the management of ulcerative colitis include:

• The use of fecal calprotectin <150 mg/g, normal fecal lactoferrin, or normal CRP to rule out active inflammation and avoid routine endoscopic assessment of disease activity 1
• The use of fecal calprotectin >150 mg/g, elevated fecal lactoferrin, or elevated CRP to rule in active inflammation and inform treatment adjustment 1
• The importance of considering the patient's preferences and values in making treatment decisions, as well as the potential risks and benefits of different treatment strategies 1

From the FDA Drug Label

The recommended dose of RENFLEXIS is 5 mg/kg given as an intravenous induction regimen at 0,2 and 6 weeks followed by a maintenance regimen of 5 mg/kg every 8 weeks thereafter for the treatment of adult patients with moderately to severely active ulcerative colitis. In Study UC I, this effect was maintained through Week 54 (21% in infliximab treatment groups vs. 9% in placebo group). 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 approach for a 75-year-old man with diffuse active colitis in the sigmoid colon and transverse colon, diagnosed via mucosal biopsy, is to administer infliximab (IV) at a dose of 5 mg/kg given as an intravenous induction regimen at 0,2, and 6 weeks followed by a maintenance regimen of 5 mg/kg every 8 weeks.

• Key considerations:
  • The patient's age and medical history should be taken into account when making treatment decisions.
  • Close monitoring for signs and symptoms of infection is necessary during and after treatment with infliximab.
  • The patient should be closely monitored for the development of signs and symptoms of infection during and after treatment with infliximab, including the possible development of tuberculosis in patients who tested negative for latent tuberculosis infection prior to initiating therapy 2 2.

From the Research

Treatment Approach

The treatment approach for a 75-year-old man with diffuse active colitis in the sigmoid colon and transverse colon, diagnosed via mucosal biopsy, may involve the following:

• Induction of remission using mesalamine, a 5-aminosalicylic acid compound, which is the first-line treatment for patients with mild-to-moderate ulcerative colitis 3
• Use of corticosteroids, such as systemic or topical administration, for patients with severe ulcerative colitis or those who do not respond to mesalamine 4, 5, 6
• Topical administration of corticosteroids, such as beclomethasone dipropionate or budesonide, as an alternative to systemic corticosteroids 5, 6

Management Considerations

Management considerations for this patient may include:

• Determining the optimal dose of mesalamine for induction of response and maintenance of remission 3
• Monitoring for adverse effects of corticosteroids, such as bone fracture risk, and considering alternative treatments to minimize these risks 4, 6
• Considering the use of immunosuppressive agents, such as azathioprine or mercaptopurine, for patients with chronically active or corticosteroid-dependent disease 5
• Evaluating the need for surgical intervention, such as proctocolectomy, in patients who do not respond to medical therapy 7

Maintenance Therapy

Maintenance therapy for this patient may involve:

• Use of mesalamine or sulfasalazine to maintain clinical remission 3, 5
• Consideration of alternative drugs, such as 5-lipoxygenase inhibitors or topical use of short chain fatty acids, for patients who do not respond to traditional therapies 5
• Regular monitoring for signs of disease activity and adjustment of treatment as needed to maintain remission and prevent complications 7