What are the treatment options for colitis?

Treatment of Colitis

The treatment of colitis should be tailored based on disease type, location, and severity, with mesalazine (5-ASA) being the first-line treatment for mild to moderate ulcerative colitis and corticosteroids for moderate to severe disease. 1, 2

Diagnostic Approach

• Infectious causes of diarrhea should be excluded before diagnosing and treating inflammatory bowel disease (IBD) 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
• Endoscopic confirmation of diagnosis and severity should be considered before initiating high-dose systemic glucocorticoids for suspected IBD 2

Treatment Based on Disease Location and Severity

Mild to Moderate Disease

• For proctitis (rectal involvement only), first-line treatment is mesalazine (5-ASA) 1g suppository once daily 1
• For mild to moderate left-sided or extensive colitis, first-line treatment is oral mesalazine 2-4g daily, which can be combined with topical mesalazine for better efficacy 1, 2
• Topical corticosteroids can be used as second-line therapy for those intolerant to topical mesalazine 2

Moderate to Severe Disease

• First-line treatment is oral prednisolone combined with mesalazine 1
• Prednisolone should be reduced gradually according to severity and patient response, generally over 8 weeks 3
• For patients who fail to respond to corticosteroids, biologics such as infliximab may be considered 4

Acute Severe Colitis

• Intravenous corticosteroids are the mainstay of therapy for acute severe colitis 5
• Medical rescue therapy with cyclosporine or infliximab should be considered if there is no response to corticosteroids after 3 days 5
• If no response to medical rescue therapy after 4-7 days, emergency colectomy is indicated 6, 5
• Subtotal colectomy with ileostomy is the preferred surgical approach in emergency settings 1, 5

Maintenance Therapy

• Lifelong maintenance therapy is recommended for all patients with ulcerative colitis, particularly those with left-sided or extensive disease 1, 3
• Maintenance therapy should continue with the agent successful in achieving induction, except corticosteroids which are not recommended for long-term maintenance 1, 3
• For patients in remission on 5-ASA, continuation is generally recommended at a dose of at least 2 g/day 3
• Azathioprine or mercaptopurine can be used as second-line maintenance therapy, though they have potential toxicity 2

Special Considerations

Venous Thromboembolism Prophylaxis

• Administer venous thromboembolism prophylaxis with LMWH as soon as possible due to the high risk of thrombotic events related to complicated IBD 6

Nutritional Support

• Administer nutritional support (parenteral or enteral, according to GI function) in IBD patients as soon as possible 6

Medication Management Before Surgery

• Wean off steroids (ideally 4 weeks before surgery) and stop immunomodulators associated with anti-TNF-α agents before surgery to decrease the risk of postoperative complications 6

Indications for Surgery

• Failure to improve or deterioration within 48-72 hours from initiation of medical therapy in acute severe ulcerative colitis 6
• Surgical complications such as free perforation, life-threatening hemorrhage, or generalized peritonitis 6
• Toxic megacolon complicated by perforation, massive bleeding, clinical deterioration, or signs of shock 6
• No response to intravenous steroids within 3-5 days 3
• No response to second-line therapy 6, 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
• 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
• Avoiding antibiotics for Shiga toxin-producing E. coli (STEC) infections as treatment may increase risk of complications 2

Monitoring Response

• Evaluate clinical response within 2 weeks for corticosteroid therapy and at 8-12 weeks for biologics 2
• Patients with persistent symptoms despite optimized therapy may require hospitalization for intravenous steroids 2
• Anti-diarrheal medications should be avoided to prevent toxic megacolon 2