What are the treatment options for colitis?

Treatment Options for Colitis

The treatment of colitis is primarily guided by the type of colitis, disease location, and severity, with mesalazine (5-ASA) being the first-line therapy for mild to moderate ulcerative colitis, while more severe cases require corticosteroids, immunomodulators, or biologics. 1, 2

Diagnostic Approach

• Before initiating treatment, infectious causes of colitis must be excluded through appropriate stool testing 2
• Endoscopic confirmation with biopsies is essential to establish the diagnosis and assess disease extent and severity 2
• Disease severity should be classified as mild, moderate, or severe based on clinical parameters, with severe disease defined by bloody stool frequency ≥6/day plus at least one of: tachycardia >90/min, temperature >37.8°C, hemoglobin <10.5 g/dl, or ESR >30 mm/h (CRP >30 mg/l can substitute for ESR) 1

Treatment Based on Disease Location

Proctitis (Rectal Involvement Only)

• First-line: Mesalazine (5-ASA) 1g suppository once daily 1
• Alternative: Mesalazine foam or enemas, though suppositories deliver the drug more effectively to the rectum and are better tolerated 1
• For inadequate response: Combine topical mesalazine with oral mesalazine or add topical corticosteroids 1
• For refractory proctitis: Systemic corticosteroids, immunosuppressants, JAK inhibitors, S1P agonists, or biologics may be required 1

Mild to Moderate Left-Sided or Extensive Colitis

• First-line: Oral mesalazine 2-4g daily, which can be combined with topical mesalazine for better efficacy 1, 2
• If no response within 2-4 weeks: Initiate oral corticosteroids (prednisolone) 1
• Maintenance therapy: Continue with the agent successful in induction, except corticosteroids which are not recommended for long-term use 1, 3

Moderate to Severe Colitis

• First-line: Oral prednisolone combined with mesalazine 1
• If no response to oral corticosteroids within 2 weeks: Consider advanced therapy (biologics or small molecules) 1
• For maintenance: Purine analogues (azathioprine, mercaptopurine) can be used, often alongside infliximab for better outcomes 1

Treatment of Acute Severe Colitis

• Hospitalization is required for intravenous corticosteroids 4
• If no improvement within 3-5 days of IV steroids: Consider rescue therapy with cyclosporine or infliximab 4
• If no response to rescue therapy within 4-7 days: Emergency colectomy is mandatory 1, 4
• Subtotal colectomy with ileostomy is the preferred surgical approach in emergency settings 1

Biologic Therapy for Ulcerative Colitis

• Infliximab is indicated for reducing signs and symptoms, inducing and maintaining clinical remission and mucosal healing, and eliminating corticosteroid use in adult patients with moderately to severely active disease who have had an inadequate response to conventional therapy 5
• Infliximab is also indicated for pediatric patients with moderately to severely active ulcerative colitis who have had inadequate response to conventional therapy 5
• Typical dosing: 5 mg/kg at weeks 0,2, and 6, then every 8 weeks thereafter 5

Maintenance Therapy Considerations

• Lifelong maintenance therapy is recommended for all patients with ulcerative colitis, particularly those with left-sided or extensive disease 3
• Patients with distal disease who relapse more than once a year should remain on maintenance therapy indefinitely 3
• Maintenance therapy should continue with the agent successful in achieving induction, except corticosteroids which are not recommended for long-term maintenance 1, 3

Important Pitfalls to Avoid

• Delaying surgery in critically ill patients with toxic megacolon, as this increases the risk of perforation with high mortality 1, 4
• Using corticosteroids for long-term maintenance therapy due to significant adverse effects 1, 3
• Continuing 5-ASAs in patients who have failed these agents and escalated to advanced therapies, unless they have residual proctitis 3
• Inadequate assessment of disease severity leading to inappropriate treatment selection 1

Treatment Goals

• The overall treatment goal has shifted from achieving clinical response to achieving biochemical, endoscopic, and histological remission to prevent long-term disease complications 1
• Complete remission is defined as durable symptomatic and endoscopic remission without corticosteroid therapy 6

By following this treatment algorithm based on disease location and severity, most patients with colitis can achieve and maintain remission, improving their quality of life and preventing disease complications.