Initial Approach to Non-Clostridioides difficile Colitis
For patients with non-C. difficile colitis, the initial treatment should focus on 5-aminosalicylates for mild to moderate disease, while moderate to severe disease requires corticosteroids or biologic agents depending on disease severity. 1
Assessment and Classification
- First determine the severity of colitis based on clinical parameters including stool frequency, presence of blood, fever, tachycardia, anemia, and inflammatory markers 1
- Exclude infectious causes, particularly C. difficile, before initiating treatment 2
- Classify disease extent (proctitis, left-sided, or extensive/pancolitis) as this influences treatment approach 1
Treatment Algorithm by Disease Severity
Mild to Moderate Disease
- First-line treatment: high-dose oral mesalazine (5-aminosalicylate) at 4g daily 3, 1
- For distal colitis, combine oral mesalazine with topical mesalazine for better efficacy 1
- Topical mesalazine may be effective for left-sided colonic disease of mild to moderate activity 3
- Sulphasalazine 4g daily is effective for active colonic disease but has more side effects than mesalazine 3
Moderate to Severe Disease
- For patients with moderate to severe disease, or those failing mesalazine therapy, oral corticosteroids such as prednisolone 40mg daily are appropriate 3, 1
- Prednisolone should be reduced gradually over 8 weeks; rapid reduction is associated with early relapse 3
- Budesonide 9mg daily is appropriate for isolated ileo-cecal disease with moderate activity, though slightly less effective than prednisolone 3
Severe or Fulminant Disease
- Intravenous steroids (hydrocortisone 400mg/day or methylprednisolone 60mg/day) are appropriate for severe disease 3
- Concomitant intravenous metronidazole is often advisable to cover potential septic complications 3
- Early surgical consultation should be considered for patients with severe disease not responding to medical therapy 1
- Joint management by gastroenterologist and colorectal surgeon is recommended 1
Adjunctive Therapies
- Elemental or polymeric diets are appropriate adjunctive therapy but less effective than corticosteroids as primary treatment 3
- Total parenteral nutrition is appropriate adjunctive therapy in complex, fistulating disease 3
- Metronidazole (10-20mg/kg/day) may have a role in selected patients with colonic or treatment-resistant disease 3
- Azathioprine (1.5-2.5mg/kg/day) or mercaptopurine (0.75-1.5mg/kg/day) may be used as adjunctive therapy and steroid-sparing agents, but their slow onset of action precludes use as sole therapy 3
Biologic Therapy Options
- For moderate-severe disease failing conventional therapy, biologic agents should be considered 1
- Infliximab 5mg/kg is effective but should be avoided in patients with obstructive symptoms 3
- TNF-α antagonists (infliximab, adalimumab, golimumab), vedolizumab, ustekinumab, or JAK inhibitors (tofacitinib, upadacitinib) are biologic options 1
- For biologic-naive patients, infliximab or vedolizumab are preferred over adalimumab for induction of remission 1
Important Clinical Considerations
- Patients should be encouraged to participate actively in treatment decisions 3
- Frequent assessments are required to determine clinical response, with treatment intensification if improvement goals aren't met 4
- Surgery should be considered for those who have failed medical therapy and may be appropriate as primary therapy in patients with limited ileal or ileo-cecal disease 3
- Recognize that acute onset colitis can be difficult to distinguish from infectious colitis, but treatment should not be delayed while awaiting stool microbiology results 1
Maintenance Therapy
- After achieving remission, maintenance therapy is generally recommended, especially for patients with left-sided or extensive disease 1
- Options include 5-aminosalicylates, azathioprine, or mercaptopurine 1
- In patients who achieve remission with biologics and/or immunomodulators, continuing 5-aminosalicylates for maintenance may not be necessary 1