What is the initial treatment for a patient with colitis?

Initial Treatment for Colitis

For patients with colitis, the initial treatment should be a combination of topical mesalazine 1 g/day with oral mesalazine ≥ 2.4 g/day, as this combination therapy is more effective than either treatment alone for controlling inflammation and symptoms. 1

Treatment Algorithm Based on Disease Severity and Location

Mild to Moderate Distal/Left-sided Colitis

• Combination therapy with topical mesalazine (≥1 g/day) plus oral mesalazine (≥2.4 g/day) is the most effective first-line approach 1
• Once-daily dosing with mesalazine is as effective as divided doses and may improve adherence 1
• Topical mesalazine is more effective than topical corticosteroids and should be preferred 1

Moderate to Severe or Non-responsive Colitis

• Oral prednisolone 40 mg daily is appropriate when prompt response is required or mesalazine has been unsuccessful 1, 2
• Prednisolone should be reduced gradually over 8 weeks according to severity and patient response; more rapid reduction is associated with early relapse 3, 2
• 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 1

Severe Colitis

• Intravenous steroids (hydrocortisone 400 mg/day or methylprednisolone 60 mg/day) are appropriate 3, 2
• Hospitalization is required with close monitoring 1
• Joint management by a gastroenterologist and colorectal surgeon is essential 1
• Patients should be informed about a 25-30% chance of needing colectomy 1

Special Considerations for Crohn's Colitis

Mild Ileocolonic Crohn's Disease

• High dose mesalazine (4 g/daily) may be sufficient initial therapy 3
• Efficacy of oral mesalazine has been demonstrated in controlled trials to be superior to placebo in mild to moderate disease 4

Moderate to Severe Crohn's Colitis

• Oral corticosteroids such as prednisolone 40 mg daily is appropriate for patients with moderate to severe disease, or those with mild to moderate ileocolonic CD that has failed to respond to oral mesalazine 3
• Sulphasalazine 4 g daily is effective for active colonic disease but has a high incidence of side effects 3
• Metronidazole 10–20 mg/kg/day can be considered in selected patients with colonic disease or those who wish to avoid steroids 3

Important Clinical Pearls

• Always exclude infectious causes before attributing symptoms to IBD flare 1, 2
• Long-term steroid use should be avoided due to side effects 1, 2
• Maintenance therapy should be continued after remission is achieved to prevent relapse 1, 5
• Lifelong maintenance therapy is generally recommended, especially for those with left-sided or extensive disease 1
• For patients with fistulating disease or perianal involvement, different treatment approaches may be needed 3

Treatment Efficacy and Monitoring

• Clinical improvement should be assessed within 2-4 weeks of initiating therapy 2
• Mesalazine has demonstrated ability to induce endoscopic remission in up to 45% of patients treated with topical formulations and 30% with oral formulations 6
• The efficacy of aminosalicylates is dose-related, with little benefit demonstrable in Crohn's disease at oral doses < 2 g/day 7
• If no improvement is seen with initial therapy, consider stepping up treatment or reassessing the diagnosis 1, 2

By following this evidence-based approach to the initial treatment of colitis, clinicians can effectively manage symptoms, reduce inflammation, and improve patient outcomes while minimizing potential adverse effects.