What is the treatment for colitis?

Treatment for Colitis

The treatment for 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

Initial Treatment Based on Disease Extent

Proctitis (Rectal Involvement)

• First-line: Mesalazine 1g suppository once daily as the preferred initial treatment 2
• Mesalazine foam or enemas are alternatives, but suppositories deliver the drug more effectively to the rectum and are better tolerated 2
• Topical mesalazine is more effective than topical corticosteroids and should be preferred 2

Left-Sided Colitis

• First-line: Combination of aminosalicylate enema ≥1g/day with oral mesalazine ≥2.4g/day 2
• This combination is more effective than oral or topical aminosalicylates, or topical steroids alone 2
• Once-daily dosing with mesalazine is as effective as divided doses and may improve adherence 2

Extensive Colitis/Pancolitis

• First-line: Oral aminosalicylates (mesalazine 2-4g daily, balsalazide 6.75g daily, or olsalazine 1.5-3g daily) 3
• Combination of oral and topical mesalazine is more effective than either alone for achieving remission 3
• Topical therapy (mesalazine enemas 1g daily) can be added for troublesome rectal symptoms 3

Treatment Escalation Algorithm

Step 1: Optimize 5-ASA Therapy

• Start with high-dose mesalazine (4.8g/day) rather than starting at a lower dose and increasing if treatment fails 4
• Continue treatment for up to 40 days before determining failure, as sustained complete remission may take time 2
• The median time to cessation of rectal bleeding is approximately 9 days with high-dose mesalazine (4.8g/day) compared to 16 days with standard dose (2.4g/day) 2

Step 2: Add Corticosteroids if Inadequate Response

• If no improvement within 10-14 days or symptoms worsen on optimized mesalazine therapy, add oral corticosteroids 2
• Oral prednisolone 40mg daily with tapering over 6-8 weeks is the standard approach 2
• Alternatively, consider budesonide MMX 9mg/day for left-sided disease as it has fewer systemic side effects than conventional steroids 2

Step 3: Consider Biologics for Refractory Disease

• For moderate to severe ulcerative colitis with inadequate response to conventional therapy, infliximab is FDA-approved 5
• The recommended dose of infliximab is 5mg/kg given as an intravenous induction regimen at 0,2, and 6 weeks followed by a maintenance regimen of 5mg/kg every 8 weeks 5

Maintenance Therapy

• Lifelong maintenance therapy is generally recommended, especially for those with left-sided or extensive disease 1
• 5-ASA compounds are effective and safe for maintenance therapy 3
• For steroid-dependent disease, consider immunomodulators: Azathioprine 1.5-2.5mg/kg/day or Mercaptopurine 0.75-1.5mg/kg/day 3

Special Considerations and Monitoring

Medication Side Effects

• Regular monitoring of renal function is recommended for patients on long-term 5-ASA therapy, including eGFR before starting, after 2-3 months, and then annually 2
• Approximately 50% of patients experience short-term corticosteroid-related adverse events such as acne, edema, sleep and mood disturbance, glucose intolerance, and dyspepsia 2
• Long-term steroid use should be avoided due to significant side effects 3

Common Pitfalls and Caveats

• Proximal constipation should be treated with stool bulking agents or laxatives 3
• Antidiarrheal medications can mask worsening symptoms while allowing underlying inflammation to progress 3
• Sulfasalazine (2-4g daily) has a higher incidence of side effects compared to newer aminosalicylates 3
• When using biologics like infliximab, there is an increased risk of serious infections including tuberculosis, bacterial sepsis, and invasive fungal infections 5
• Lymphoma and other malignancies have been reported in patients treated with TNF blockers including infliximab products 5
• Patients who required two or more courses of corticosteroids in the past year, or who become corticosteroid-dependent or refractory, require treatment escalation with thiopurine, anti-TNF therapy, vedolizumab, or tofacitinib 2