What is the recommended dosage of mesalazine (mesalamine) for the treatment of chronic proctitis?

Mesalazine Dosage for Chronic Proctitis

For patients with chronic ulcerative proctitis, the recommended dosage of mesalazine is 1 gram suppository once daily, preferably at bedtime. 1

First-Line Treatment Options

• Mesalazine 1 gram suppository once daily is the preferred initial treatment for mild to moderate proctitis 1
• Suppositories are more appropriate than enemas for proctitis as they better target the site of inflammation and are more acceptable to patients 1
• The suppository should be retained for approximately eight hours for optimal effect 2
• Treatment duration is typically 3-6 weeks depending on symptoms and sigmoidoscopic findings 2

Efficacy and Evidence

• The American Gastroenterological Association (AGA) strongly recommends mesalazine suppositories for patients with mild-moderate ulcerative proctitis who choose rectal therapy over oral therapy (Strong recommendation, moderate quality evidence) 1
• Mesalazine suppositories are superior to placebo in inducing remission with a pooled risk ratio of 0.44 (95% CI 0.34-0.56) 1
• Topical mesalazine is more effective than topical steroids for inducing remission 1
• Once-daily dosing of high-dose (1g) mesalazine suppository is as effective as thrice-daily administration of 0.5g suppositories, but more convenient for patients 3

Alternative Dosing Regimens

• For maintenance therapy after remission is achieved, mesalazine suppositories 1g three times per week can be effective in preventing relapses 4
• If symptoms persist or worsen, consider increasing to 1g daily for treatment of relapse 4
• For more severe cases, combination therapy may be considered:
  • Topical mesalazine 1g daily combined with oral mesalazine 2-4g daily is an effective first-line therapy for mild to moderate disease 1
  • Combination of topical and oral therapy is more effective than either treatment alone 1

Treatment Alternatives for Refractory Cases

• For patients intolerant of or refractory to mesalazine suppositories, rectal corticosteroid therapy can be considered 1
• If patients fail to improve on combination of oral mesalazine with either topical mesalazine or topical corticosteroids, oral prednisolone 40mg daily may be required 1
• Patients with chronic active steroid-dependent disease should be considered for immunosuppressive therapy 1

Important Considerations and Monitoring

• Evaluate renal function prior to initiation of mesalazine therapy and periodically during treatment 2
• Ensure adequate hydration during treatment to prevent nephrolithiasis 2
• Monitor for hypersensitivity reactions, which may include sulfite-related reactions as mesalazine rectal suspension contains potassium metabisulfite 2
• Discontinue treatment if acute intolerance syndrome (cramping, acute abdominal pain, bloody diarrhea, sometimes fever, headache and rash) is suspected 2

Common Pitfalls to Avoid

• Inadequate treatment duration - therapy should continue for 3-6 weeks depending on symptoms and sigmoidoscopic findings 2
• Insufficient patient education about proper administration technique and retention time (approximately 8 hours) 2
• Failure to treat proximal constipation, which should be addressed with stool bulking agents or laxatives 1
• Not considering combination therapy (topical plus oral mesalazine) when response to topical therapy alone is suboptimal 1