Would you use mesalamine (5-aminosalicylic acid) rectally in a patient with an ileostomy (surgical creation of an opening in the intestine)?

Mesalamine Rectal Therapy in Patients with Ileostomy

Rectal mesalamine therapy is not recommended for patients with an ileostomy as it would be ineffective due to the surgical diversion of intestinal contents away from the rectum. 1

Rationale for Not Using Rectal Mesalamine in Ileostomy Patients

• An ileostomy surgically diverts intestinal contents through an opening in the abdominal wall, bypassing the colon and rectum completely 1
• Rectal mesalamine formulations (suppositories, enemas, foams) are designed to deliver the active medication directly to the inflamed rectal and colonic mucosa 1
• In patients with an ileostomy, the fecal stream no longer passes through the rectum, making topical therapy ineffective as the medication cannot reach its intended target 1
• The diverted rectum in patients with ileostomy may develop diversion colitis, but this condition requires different management approaches 2

Therapeutic Considerations for Ulcerative Colitis Patients with Ileostomy

• For patients with an ileostomy who have remaining rectal tissue with active inflammation, systemic therapy would be more appropriate than rectal formulations 1
• Oral mesalamine at standard doses (2-3g/day) would be the preferred approach for mild-moderate inflammation in any remaining colorectal tissue 1
• For moderate-to-severe inflammation in remaining rectal tissue, systemic corticosteroids, immunomodulators, or biologics may be necessary 1

Understanding Rectal Mesalamine Delivery

• Rectal mesalamine formulations are specifically designed to treat distal colitis (proctitis or proctosigmoiditis) by direct mucosal contact 1
• Mesalamine enemas can reach as far as the splenic flexure but require an intact rectal passage for proper administration and retention 3
• Suppositories are effective for proctitis (inflammation limited to 15-20cm from the anal verge) 1
• The efficacy of these formulations depends on:
  • Direct contact with inflamed mucosa 1, 4
  • Adequate retention time 1, 3
  • Patient's ability to administer and hold the medication 1

Alternative Approaches for Patients with Ileostomy

• For patients with remaining rectal inflammation after ileostomy:
  • Oral systemic therapy should be the primary approach 1
  • If surgical options are being considered, completing proctectomy may be appropriate rather than attempting topical therapy 2
  • In cases of diversion colitis (inflammation in the diverted segment), combined systemic therapy may be required before definitive surgical management 2

Clinical Pitfalls to Avoid

• Attempting rectal therapy in patients with ileostomy wastes resources and delays effective treatment 1
• Misunderstanding the mechanism of action of topical therapy can lead to inappropriate prescribing 5, 4
• Failing to recognize that an ileostomy fundamentally changes the approach to treating any remaining colorectal tissue 2
• Not considering the complete surgical history when planning medical therapy for inflammatory bowel disease 1