What is the recommended management for colitis?

Management of Colitis

For colitis management, the first-line treatment should be mesalamine (5-ASA) at a standard dose of 2-3 grams/day for mild to moderate disease, with treatment approach tailored to disease extent and severity. 1, 2

Treatment Based on Disease Extent

Extensive/Pancolitis

• Use standard dose mesalamine (2-3 grams/day) or diazo-bonded 5-ASA as initial therapy 3
• Add rectal mesalamine to oral therapy for better efficacy 3, 1
• Consider once-daily dosing rather than multiple times per day for improved adherence 3, 2
• For suboptimal response, increase to high-dose mesalamine (>3 grams/day) with rectal mesalamine 3, 2

Left-sided/Sigmoid Colitis

• Combine oral mesalamine (2-4g daily) with topical mesalamine (1g daily) for optimal efficacy 1
• For sigmoid involvement, mesalamine enemas are more effective than oral therapy alone 3, 1
• Topical mesalamine is more effective than topical corticosteroids 3, 1
• Choose appropriate topical formulation based on disease extent: suppositories for rectosigmoid junction, foam or liquid enemas for more proximal disease 1

Proctitis/Proctosigmoiditis

• Use mesalamine enemas or suppositories rather than oral mesalamine as first-line treatment 3, 2
• Patients who prioritize convenience over effectiveness may choose oral mesalamine 3

Treatment for Microscopic Colitis

• Budesonide is strongly recommended as first-line therapy over mesalamine or no treatment for symptomatic microscopic colitis 3
• Standard dosing is 9 mg daily for induction of remission 3
• For patients with recurrent symptoms after stopping induction therapy, maintenance therapy with budesonide is recommended (6 mg daily, potentially tapering to lowest effective dose) 3
• If budesonide therapy is not feasible, consider:
  • Mesalamine (conditional recommendation) 3
  • Bismuth salicylate (conditional recommendation) 3
  • Prednisolone/prednisone (conditional recommendation) 3
• Not recommended: combination therapy with cholestyramine and mesalamine, Boswellia serrata, or probiotics 3

Treatment Escalation for Inadequate Response

For Mild-Moderate Disease

• If standard-dose mesalamine fails, increase to high-dose mesalamine (>3 grams/day) with rectal mesalamine 3, 2
• For non-response to optimized 5-ASA therapy, initiate oral prednisolone 40mg daily 1, 4
• Taper prednisolone gradually over 8 weeks; rapid reduction is associated with early relapse 1, 4

For Moderate-Severe Disease

• For patients with inadequate response to conventional therapy, infliximab is FDA-approved for moderately to severely active ulcerative colitis 5, 6
• Standard infliximab dosing: 5 mg/kg at weeks 0,2, and 6, followed by maintenance dosing every 8 weeks 5

For Steroid-Dependent Disease

• Consider immunomodulators: azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.5 mg/kg/day) 1, 4
• Long-term steroid treatment should be avoided due to significant side effects 1, 4

Maintenance Therapy

• Lifelong maintenance therapy is generally recommended for all patients with extensive disease 4
• Aminosalicylates are effective and safe for maintenance therapy 4
• For microscopic colitis requiring maintenance therapy, budesonide is recommended 3
• Consider stopping maintenance therapy after 6-12 months for microscopic colitis 3

Common Pitfalls and Caveats

• Ensure adequate dosing of mesalamine (at least 2g daily for active disease) 1, 7
• Avoid delaying corticosteroid treatment if no response to optimized 5-ASA therapy 1
• Avoid long-term steroid use; transition to steroid-sparing agents if needed 1, 4
• Antidiarrheal medications should be avoided as they can mask worsening symptoms while allowing underlying inflammation to progress 1, 4
• Proximal constipation should be treated with stool bulking agents or laxatives 1, 4
• Sulfasalazine has more side effects than newer 5-ASA formulations but may be beneficial for patients with reactive arthropathy 1, 8
• For microscopic colitis, osteoporosis prevention and screening should be considered in patients requiring maintenance budesonide therapy 3