What are the treatment options for colitis?

Treatment Options 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

Treatment Based on Disease Extent

Proctitis (Disease Limited to Rectum)

• Mesalamine 1g suppository once daily is the preferred initial treatment for mild or moderately active proctitis 2
• Mesalamine foam or enemas are alternatives, but suppositories deliver the drug more effectively to the rectum and are better tolerated 2
• Topical mesalamine is more effective than topical steroids 2, 1
• Combining topical mesalamine with oral mesalamine or topical steroids is more effective than either alone 2, 1
• Refractory proctitis may require treatment with systemic steroids, immunosuppressants, and/or biologics 2

Distal Colitis (Left-sided)

• Topical mesalamine 1g daily combined with oral mesalamine 2-4g daily is effective first-line therapy 2, 1
• Topical formulation should be selected based on disease extent: foam or liquid enemas for more proximal disease 1
• Topical corticosteroids are less effective than topical mesalamine and should be reserved as second-line therapy 2
• Patients who fail to improve on combination therapy should be treated with oral prednisolone 40mg daily 2, 1
• Proximal constipation should be treated with stool bulking agents or laxatives 2, 1

Extensive Colitis

• Oral mesalamine ≥2.4g daily combined with topical mesalamine enemas 1g daily is recommended 1
• Systemic corticosteroids (prednisolone 40mg daily) are appropriate for moderate to severe disease or for patients with mild disease who don't respond to mesalamine 1
• Prednisolone should be tapered gradually over approximately 8 weeks according to patient response 2, 1

Treatment Based on Disease Severity

Mild to Moderate Disease

• Aminosalicylates (5-ASA) are first-line therapy 1
• Options include:
  • Mesalamine (2-4g daily) 2, 1
  • Balsalazide (6.75g daily) 2, 1
  • Olsalazine (1.5-3g daily) 2, 1
  • Sulfasalazine (2-4g daily) - has higher incidence of side effects compared to newer 5-ASA drugs 2, 1
• Once-daily dosing with mesalamine is as effective as divided doses 1
• Combination of oral and topical 5-ASA is more effective than either alone 1

Severe Disease

• Requires hospital admission for intensive treatment 2, 1
• Joint management by gastroenterologist and colorectal surgeon 1
• Intravenous fluid and electrolyte replacement 2
• Blood transfusion to maintain hemoglobin >10 g/dl 2
• Subcutaneous heparin to reduce the risk of thromboembolism 2
• Nutritional support if the patient is malnourished 2
• Daily monitoring of vital signs, stool frequency, and laboratory parameters 2

Advanced Treatment Options

Steroid-Dependent or Refractory Disease

• Azathioprine (1.5-2.5mg/kg/day) or mercaptopurine (0.75-1.5mg/kg/day) are indicated 1
• Infliximab is indicated for reducing signs and symptoms, inducing and maintaining clinical remission and mucosal healing, and eliminating corticosteroid use in adult patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy 3
• The recommended dose of infliximab 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 3

Maintenance Therapy

• Lifelong maintenance therapy is generally recommended, especially for left-sided or extensive disease 2, 1
• 5-ASA compounds are effective and safe for maintenance therapy 1
• Immunomodulators can be used for maintenance in steroid-dependent patients 1

Safety Considerations

• Mesalamine is generally well tolerated but can cause serious adverse effects including worsening of colitis, interstitial pneumonitis, and nephritis 4
• These reactions are mostly reversible with cessation of therapy 4
• Patients on immunosuppressive therapy should be monitored for infections 5
• Patients receiving infliximab should be evaluated for tuberculosis and other infections before starting therapy 3
• Lymphoma and other malignancies have been reported in patients treated with TNF blockers, including infliximab 3

Treatment Efficacy

• Mesalamine has been demonstrated in randomized controlled trials to induce both clinical response and remission, and maintain clinical remission 6
• High-dose 5-ASA therapy may be valuable for patients with moderately active disease 7
• Extending mesalamine treatment to at least 34 weeks can be beneficial in inducing complete remission in patients unresponsive to conventional therapy 8