From the Guidelines
I treat symptomatic colitis with budesonide as the first-line therapy, given its strong recommendation and moderate quality of evidence for inducing clinical remission. This approach is based on the American Gastroenterological Association (AGA) guideline on the medical management of microscopic colitis 1. The guideline recommends budesonide over no treatment for the induction of clinical remission in patients with symptomatic microscopic colitis, with a strong recommendation and moderate quality of evidence.
Key Considerations
- Budesonide has been shown to be effective in inducing clinical response and histological response, with a significant improvement in quality of life, although the difference did not reach statistical significance 1.
- The recommended dose of budesonide is 9 mg daily, which has been shown to be more effective than lower doses in inducing clinical remission 1.
- Alternative therapies, such as mesalamine, may be considered if budesonide is not feasible or if cost is a determining factor 1.
Management of Immune-Related Adverse Events
In cases of immune-related adverse events, such as those associated with immune checkpoint inhibitor therapy, the management of colitis may involve the use of corticosteroids, infliximab, or vedolizumab 1. However, the primary approach for symptomatic colitis remains the use of budesonide as the first-line therapy.
Stepwise Approach
For mild to moderate cases, dietary modifications and medications such as anti-diarrheals and antispasmodics may be used for symptom control. However, budesonide remains the primary treatment option for inducing clinical remission in symptomatic colitis, with other therapies being considered based on the underlying cause and severity of the condition.
From the FDA Drug Label
RENFLEXIS is a tumor necrosis factor (TNF) blocker indicated for: Ulcerative Colitis: • 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. (1. 3) Pediatric Ulcerative Colitis: • reducing signs and symptoms and inducing and maintaining clinical remission in pediatric patients with moderately to severely active disease who have had an inadequate response to conventional therapy. (1. 4)
Infliximab (IV) is used to treat symptomatic colitis, specifically ulcerative colitis, by reducing signs and symptoms, inducing and maintaining clinical remission, and mucosal healing in adult and pediatric patients with moderately to severely active disease who have had an inadequate response to conventional therapy 2.
From the Research
Treatment of Symptomatic Colitis
- The treatment of ulcerative colitis (UC) depends on the severity of symptoms and the extent of the disease 3.
- Therapeutic goals include short-term benefits, such as reduction or absence of symptoms, and long-term benefits, including sustained clinical remission, steroid-free remission, and mucosal healing 4.
- Treatment options for moderate-to-severe UC include monoclonal antibodies, such as infliximab, adalimumab, and vedolizumab, as well as Janus Kinase inhibitors, like tofacitinib 4.
Medical Therapy
- Medical therapy is the primary treatment approach for UC, with the aim of inducing and maintaining remission 5, 6.
- Medications used to treat UC include aminosalicylates, corticosteroids, thiopurines, and biologic agents, such as infliximab and vedolizumab 6, 7.
- In cases of acute severe colitis, medical rescue therapy with cyclosporine or infliximab may be considered if there is no response to corticosteroids 3.