What is the initial treatment for colitis?

Initial Treatment of Colitis

The first-line treatment for colitis is a combination of topical mesalamine 1 g/day with oral mesalamine ≥2.4 g/day, which is more effective than either treatment alone for controlling inflammation and symptoms. 1

Treatment Algorithm Based on Disease Location and Severity

Proctitis (Distal Disease)

• Mesalamine 1-g suppository once daily is the preferred initial treatment for mild or moderately active proctitis 2
• Mesalamine foam or enemas are an alternative, but suppositories deliver the drug more effectively to the rectum and are better tolerated 2
• Topical mesalamine is more effective than topical steroids and should be preferred 2, 1
• Combining topical mesalamine with oral mesalamine is more effective than either treatment alone 2, 1

Mild to Moderate Left-Sided or Extensive Colitis

• Oral mesalamine 2-3 g/day is recommended as initial therapy 2, 1
• Adding mesalamine enemas to oral therapy is more effective than oral treatment alone 2, 1
• Once-daily dosing with mesalamine is as effective as divided doses and may improve adherence 1, 3
• For patients flaring on 5-ASA therapy, dose escalation to 4-4.8 g/day orally alongside 5-ASA enemas is recommended 2

Treatment Failure or Moderate to Severe Disease

• Oral prednisolone 40 mg daily weaning over 6-8 weeks is recommended for patients in whom 5-ASA induction therapy fails or is not tolerated 2, 1
• Budesonide MMX 9 mg/day may be an alternative to conventional steroids in patients with left-sided disease who have inadequate response to 5-ASA 2, 1
• Rapid tapering of steroids is associated with early relapse, so a gradual taper over 8 weeks is recommended 2

Special Considerations

Monitoring

• Patients on long-term 5-ASA therapy should have renal function checked, including eGFR before starting, after 2-3 months, and then annually 2
• The frequency of 5-ASA nephrotoxicity has been estimated at 1 in 4000 patient years 2

Maintenance Therapy

• Lifelong maintenance therapy is generally recommended for all patients, especially those with left-sided or extensive disease 2, 1
• Patients with distal disease who relapse more than once a year should also receive maintenance therapy 2
• Maintenance therapy reduces the risk of colorectal cancer 2, 4

Severe Colitis

• Severe ulcerative colitis requires hospitalization with intravenous steroids (hydrocortisone 400 mg/day or methylprednisolone 60 mg/day) 2
• Joint management by a gastroenterologist and colorectal surgeon is essential 2
• Patients should be informed about a 25-30% chance of needing colectomy 2, 1
• Intravenous fluid and electrolyte replacement, subcutaneous heparin, and nutritional support are important adjunctive measures 2

Common Pitfalls and Caveats

• Failure to exclude infectious causes: Always exclude infectious causes before attributing symptoms to IBD flare 1
• Inadequate dosing: Suboptimal dosing is a common reason for treatment failure; ensure adequate dosing of both oral and topical therapy 1, 5
• Poor adherence: Non-adherence to 5-ASA therapy is common (rates vary from 17% to 75%) and is associated with worse outcomes 5, 3
• Delayed escalation: Early identification of patients at high risk for 5-ASA non-response and appropriate therapeutic escalation are essential to avoid disease progression 5
• Discontinuing maintenance therapy too early: Discontinuation may be reasonable only for those with distal disease who have been in remission for 2 years 2

By following this treatment algorithm and being aware of these common pitfalls, clinicians can optimize outcomes for patients with colitis, reducing morbidity and improving quality of life.