What is the treatment for lymphocytic colitis?

Treatment of Lymphocytic Colitis

Budesonide is the first-line treatment for active lymphocytic colitis, with clinical response rates of 88% compared to 38% with placebo. 1

First-Line Treatment Options

• Budesonide: Recommended at 9 mg/day for 6-8 weeks for induction of clinical and histological response in active lymphocytic colitis 1

• Mesalazine (5-ASA): Can be used at 2.4 g/day as an alternative first-line therapy with clinical response rates of approximately 85% 1, 2

• Bismuth subsalicylate: May be effective for mild cases, though evidence is limited compared to budesonide 1, 3

• Antidiarrheals: Loperamide and diphenoxylate/atropine can be used for symptomatic relief, particularly in mild cases 3

Treatment Algorithm

Step 1: Initial Assessment and Mild Disease

• For mild symptoms, consider starting with:
  • Loperamide or diphenoxylate/atropine for symptomatic control 3
  • Bismuth subsalicylate (9 tablets of 262 mg daily) 1, 4
  • Approximately 50% of cases may gradually improve without requiring specific therapy 2

Step 2: Moderate to Severe Disease

• Budesonide 9 mg/day for 6-8 weeks is the most effective evidence-based treatment 1

  • Provides both clinical (88%) and histological (78%) response 1
  • Well-tolerated with manageable side effects including nausea, vomiting, headache 1

• Mesalazine 2.4 g/day as an alternative if budesonide is contraindicated or not tolerated 1, 2

  • Clinical response rate of approximately 85% 1
  • Side effects may include nausea and skin rash 1

Step 3: Refractory Disease

• For patients who fail initial therapy (approximately 21% of cases) 2:
  • Switch from 5-ASA to budesonide or vice versa 2
  • Consider beclometasone dipropionate (5-10 mg/day) as an alternative steroid option 1
  • Combination therapy with mesalazine plus cholestyramine (4 g/day) may be considered, though evidence suggests similar efficacy to mesalazine alone 1

Special Considerations

• Recurrent Disease: Approximately 19% of patients may experience symptom exacerbation during therapy, requiring treatment adjustments 2

  • Budesonide is the drug of choice for managing flares 2

• Maintenance Therapy: Clinical remission achieved at 8 weeks may not be maintained long-term (12-month remission rates of only 20-26%) 1

  • Consider tailored maintenance therapy for patients with frequent relapses 2

• Drug-Induced Cases: Assess and discontinue potential triggering medications, particularly NSAIDs 4

• Associated Conditions: Screen for celiac disease and other autoimmune disorders, which are commonly associated with lymphocytic colitis 4, 3

Monitoring and Follow-up

• Monitor clinical response based on reduction in bowel movements per day 2

  • Successful treatment typically reduces frequency from 5-6 to 2-3 bowel movements daily 2

• Consider follow-up colonoscopy with biopsies in refractory cases to reassess diagnosis and response 5

Common Pitfalls

• Undertreatment: No therapy produces complete response in more than 40% of patients; be prepared to adjust treatment if initial response is inadequate 3

• Overlooking associated conditions: Failure to screen for celiac disease or other autoimmune disorders may result in suboptimal treatment outcomes 4, 3

• Inadequate duration of therapy: Short courses of treatment may lead to early relapse; ensure adequate duration of initial therapy 1

• Focusing solely on diarrhea: Remember to address other symptoms like bloating, urgency, and fecal incontinence which significantly impact quality of life 3