What is the line of treatment for colitis?

Treatment Algorithm for Colitis

The treatment of 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

Initial Treatment Based on Disease Extent and Severity

Mild to Moderate Distal UC (Proctitis/Left-sided)

• A mesalamine 1-g suppository once daily is the preferred initial treatment for mild or moderately active proctitis 2
• For left-sided disease, topical mesalamine combined with oral mesalamine ≥2.4g daily is the most effective first-line therapy 1
• Topical mesalamine is more effective than topical steroids and should be the preferred topical agent 2, 1
• Suppositories are better for disease limited to rectum, while foam or liquid enemas are better for more proximal disease 1
• Once-daily dosing with mesalamine is as effective as divided doses 1, 3
• Patients who fail to improve on combination therapy should be treated with oral prednisolone 40mg daily 2, 1

Mild to Moderate Extensive UC

• Oral mesalazine 2-4g daily or balsalazide 6.75g daily are effective first-line therapy 2, 1
• Combination of oral and topical 5-ASA is more effective than either alone 1
• Sulfasalazine 4g daily is effective for active colonic disease but has higher incidence of side effects compared to newer 5-ASA drugs 2, 1
• High-dose mesalamine (4g/day) may be sufficient initial therapy for mild ileocolonic Crohn's disease 2

Moderate to Severe UC

• Oral corticosteroids such as prednisolone 40mg daily is appropriate for patients with moderate to severe disease or those who fail to respond to mesalamine 2
• Prednisolone should be reduced gradually over approximately 8 weeks according to patient response 2, 1
• In the biologic era, high-dose 5-ASA therapy may still be a valuable option for patients with moderately active disease without poor prognostic factors 4

Severe UC

• Requires hospital admission and joint management by gastroenterologist and colorectal surgeon 1
• Intravenous steroids (hydrocortisone 400mg/day or methylprednisolone 60mg/day) are appropriate for patients with severe disease 2
• After excluding alternative etiologies, intravenous methylprednisolone doses of 40-60mg/day or equivalent are mainstay of therapy 2
• Routine use of adjunctive antibiotics in patients without infections is not recommended 2

Refractory Disease Management

• Refractory proctitis may require treatment with systemic steroids, immunosuppressants, and/or biologics 2
• Patients who are refractory to 3-5 days trial of intravenous corticosteroids may be treated with either infliximab or cyclosporine 2
• Long-term treatment with steroids is undesirable; patients with chronic active steroid-dependent disease should be treated with azathioprine 1.5-2.5mg/kg/day or mercaptopurine 0.75-1.5mg/kg/day 2, 1
• In patients with moderate-severe disease activity at high risk of colectomy, biologic agents with or without an immunomodulator, or tofacitinib, should be used early rather than gradual step-up therapy after failure of 5-aminosalicylates 2

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 1, 5
• Once-daily dosing of delayed-release mesalamine is as effective as twice-daily dosing for maintenance of remission 3
• Immunomodulators can be used for maintenance in steroid-dependent patients 1
• Patients in remission with biologic agents and/or immunomodulators or tofacitinib after prior failure of 5-ASA may discontinue 5-aminosalicylates 2

Special Considerations

• A daily dosage of 2.4g appears to be a safe and effective induction therapy for patients with mild to moderately active ulcerative colitis 5
• Patients with moderate disease may benefit from an initial dose of 4.8g/day 5
• Mesalamine has few serious adverse events but nonadherence is common 6
• Common adverse events include flatulence, abdominal pain, nausea, diarrhea, headache, and worsening ulcerative colitis 5
• Treatment should aim for complete remission, assessed biochemically, endoscopically, and histologically 1
• In patients with severe ulcerative colitis who do not respond to maximum medical treatment and present infectious complications, colectomy may be necessary 7