What are the treatment options for Colitis and Cheilitis?

Treatment Options for Colitis and Cheilitis

For colitis, treatment should be tailored based on disease type (ulcerative colitis or Crohn's disease), location, and severity, with aminosalicylates as first-line therapy for mild to moderate disease and corticosteroids for more severe presentations. 1

Ulcerative Colitis Treatment

Proctitis (Distal Disease)

• A mesalamine 1-g suppository once daily is the preferred initial treatment for mild or moderately active proctitis 1
• Mesalamine foam or enemas are alternatives but suppositories deliver the drug more effectively to the rectum 1
• Topical mesalamine is more effective than topical steroids 1
• Combining topical mesalamine with oral mesalamine or topical steroids increases effectiveness 1
• Refractory proctitis may require systemic steroids, immunosuppressants, and/or biologics 1

Mild to Moderate Disease

• High-dose mesalazine (4 g/daily) is recommended as initial therapy for mild disease 1
• Oral mesalamine 2-4g daily or balsalazide 6.75g daily are effective first-line options 2, 3
• Topical mesalamine should be combined with oral therapy for distal disease to achieve faster symptom relief 2, 4
• Aminosalicylates can induce endoscopic remission comparable to anti-TNF therapy in moderate disease 3

Moderate to Severe Disease

• Oral corticosteroids such as prednisolone 40 mg daily are appropriate for moderate to severe disease or for mild to moderate disease that has failed to respond to mesalazine 1
• Prednisolone should be reduced gradually over 8 weeks to prevent early relapse 1
• Azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.5 mg/kg/day) may be used as adjunctive therapy and as steroid-sparing agents 1

Severe Disease

• Severe ulcerative colitis requires hospital admission and should be managed jointly by a gastroenterologist and colorectal surgeon 1, 2
• Intravenous steroids (hydrocortisone 400 mg/day or methylprednisolone 60 mg/day) are appropriate for severe disease 1
• Patients should be informed about a 25-30% chance of needing colectomy 1

Crohn's Disease Treatment

Mild Disease

• High-dose mesalazine (4 g/daily) may be sufficient as initial therapy for mild ileocolonic Crohn's disease 1, 5
• Budesonide 9 mg daily is appropriate for patients with isolated ileo-caecal disease with moderate activity 1

Moderate to Severe Disease

• Oral corticosteroids such as prednisolone 40 mg daily are appropriate for moderate to severe disease 1
• Elemental or polymeric diets can be used to induce remission in patients with contraindications to corticosteroid therapy 1
• Metronidazole (10-20 mg/kg/day) can be effective but is not usually first-line due to side effects 1
• Azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.5 mg/kg/day) may be used as adjunctive therapy 1
• Infliximab 5 mg/kg is effective but should be avoided in patients with obstructive symptoms 1

Severe or Fistulating Disease

• Intravenous steroids with concomitant intravenous metronidazole are appropriate for severe disease 1
• Total parenteral nutrition is appropriate adjunctive therapy in complex, fistulating disease 1
• Surgery should be considered for those who have failed medical therapy 1

Maintenance Therapy

• Patients with ulcerative colitis should receive maintenance therapy with aminosalicylates, azathioprine, or mercaptopurine to reduce relapse risk 1
• Lifelong maintenance therapy is recommended for left-sided or extensive UC 2
• For Crohn's disease, azathioprine or mercaptopurine are effective second-line maintenance options 2

Cheilitis Treatment

While the provided evidence doesn't specifically address cheilitis (inflammation of the lips), treatment typically depends on the underlying cause:

• If cheilitis is associated with inflammatory bowel disease as an extraintestinal manifestation, treating the underlying IBD with the approaches outlined above may help resolve the condition
• Topical corticosteroids may be beneficial for symptomatic relief
• If fungal in origin, antifungal medications would be appropriate
• Moisturizing agents and avoiding potential irritants are supportive measures

Special Considerations

• Mesalamine is considered safe during pregnancy with no clear evidence of increased risk of major congenital malformations 6
• Azathioprine carries increased risk of malignancy, particularly skin cancer and lymphoma, especially in patients with inflammatory bowel disease 7
• Patients with TPMT or NUDT15 deficiency may be at increased risk of severe myelotoxicity with azathioprine 7
• Always consider alternative explanations for symptoms other than active disease (bacterial overgrowth, bile salt malabsorption, fibrotic strictures) 8
• Avoid rapid reduction of corticosteroids as this is associated with early relapse 8