What are the treatment options for colitis?

Treatment of Colitis

For mild to moderate ulcerative colitis, start with mesalamine 2.4-4.8g daily orally combined with topical mesalamine 1g (suppositories for proctitis, enemas for more extensive disease), escalating to oral prednisolone 40mg daily if inadequate response after 2-4 weeks. 1, 2

Initial Treatment Strategy Based on Disease Location

Proctitis (Rectal Disease Only)

• Mesalamine 1g suppository once daily is the preferred first-line treatment 3
• Suppositories deliver medication more effectively to the rectum than foam or enemas and are better tolerated 3
• Topical mesalamine is superior to topical corticosteroids 3, 1
• Combining topical mesalamine with oral mesalamine (≥2.4g daily) is more effective than either alone 3, 1

Left-Sided/Sigmoid Colitis

• Combine oral mesalamine 2-4g daily with topical mesalamine 1g daily (enemas or foam) 1, 2
• This combination approach is more effective than monotherapy 1
• Once-daily dosing is as effective as divided doses, improving adherence 1

Extensive/Pancolitis

• Start with oral mesalamine 2.4-4.8g daily combined with topical mesalamine enemas 1g daily 1, 2, 4
• The American Gastroenterological Association recommends standard dose mesalamine (2-3g/day) or diazo-bonded 5-ASA as initial therapy 2
• Higher doses (4.8g daily of active 5-aminosalicylate) should be used from the start rather than starting low and escalating 1, 5

Treatment Escalation for Inadequate Response

Moderate Disease Not Responding to Mesalamine

• Initiate oral prednisolone 40mg daily 1, 2, 4
• Taper gradually over approximately 8 weeks according to patient response 1, 4
• Topical agents may be continued as adjunctive therapy with systemic corticosteroids 4

Severe Colitis Requiring Hospitalization

• Admit patients with bloody stool frequency ≥6/day plus any one of: tachycardia >90/min, temperature >37.8°C, hemoglobin <10.5g/dL, or ESR >30mm/h (or CRP >30mg/L) 3
• Administer intravenous methylprednisolone 40-60mg/day 3
• Joint management by gastroenterologist and colorectal surgeon is essential 3, 4
• Supportive care includes IV fluids, electrolyte replacement, blood transfusion to maintain hemoglobin >10g/dL, and subcutaneous heparin for thromboembolism prophylaxis 4

Steroid-Refractory Severe Disease

• For patients refractory to 3-5 days of IV corticosteroids, use either infliximab or cyclosporine 3
• Infliximab dosing: 5mg/kg IV at weeks 0,2, and 6, then every 8 weeks 6
• Routine adjunctive antibiotics are not recommended in patients without documented infections 3

Biologic and Advanced Therapy Positioning

First-Line Biologic Selection

• In biologic-naïve patients with moderate-severe disease, infliximab or vedolizumab are preferred over standard-dose adalimumab or golimumab 3
• In patients with prior infliximab exposure (especially primary non-responders), vedolizumab or tofacitinib may be preferred over adalimumab or golimumab 3
• Combination therapy of a biologic with an immunomodulator is more effective than monotherapy 3

Early Biologic Use

• In patients with moderate-severe disease at high risk of colectomy, use biologic agents with or without an immunomodulator, or tofacitinib, early rather than gradual step-up after 5-ASA failure 3

Maintenance Therapy

Long-Term Management

• Lifelong maintenance therapy is generally recommended, especially for left-sided or extensive disease 1, 2, 4
• Aminosalicylates are effective and safe for maintenance 1, 2
• For steroid-dependent disease, use azathioprine 1.5-2.5mg/kg/day or mercaptopurine 0.75-1.5mg/kg/day 1, 4
• Patients in remission on biologics and/or immunomodulators may discontinue 5-ASA 3

Thiopurine Considerations

• Thiopurine monotherapy should not be used for induction of remission but may be considered for maintenance 3
• Methotrexate monotherapy should not be used for induction or maintenance of remission 3

Critical Pitfalls to Avoid

Medication Errors

• Avoid antidiarrheal medications as they can mask worsening symptoms while allowing inflammation to progress and may predispose to toxic megacolon 4
• Do not use sulfasalazine as first-line therapy due to higher side effect profile compared to newer mesalamine formulations 1, 4
• Avoid long-term corticosteroid treatment due to significant adverse effects 4

Monitoring Failures

• Patients who do not respond by week 14 of biologic therapy are unlikely to respond with continued dosing and should be considered for treatment discontinuation 6
• For refractory proctitis, do not delay escalation to systemic steroids, immunosuppressants, or biologics 3

Special Populations

• In elderly patients, prefer immunomodulatory treatments with lower infection or malignancy risk and avoid long-term steroids 4
• Ensure appropriate vaccination schedules before starting immunosuppression 4
• Screen for latent tuberculosis and treat before initiating infliximab 6

Microscopic Colitis (Distinct Entity)

• Budesonide 9mg daily is first-line therapy over mesalamine for symptomatic microscopic colitis 2
• This represents a different treatment paradigm than ulcerative colitis 2