What are the primary care physician's (PCP) management options for colitis, particularly mild to moderate ulcerative colitis?

Primary Care Management of Mild-to-Moderate Ulcerative Colitis

For extensive mild-to-moderate ulcerative colitis, initiate standard-dose oral mesalamine (2-3 grams/day) or diazo-bonded 5-ASA as first-line therapy, with consideration for adding rectal mesalamine to enhance efficacy. 1

Initial Treatment Strategy by Disease Location

Extensive or Left-Sided Colitis

• Start with standard-dose oral mesalamine (2-3 grams/day) or diazo-bonded 5-ASA rather than low-dose mesalamine, sulfasalazine, or no treatment 1
• Once-daily dosing is as effective as multiple-times-per-day dosing and improves adherence 1, 2
• Add rectal mesalamine to oral 5-ASA to improve remission rates in extensive or left-sided disease 1

Proctosigmoiditis (Left-Sided Disease)

• Mesalamine enemas are preferred over oral mesalamine for left-sided disease 1
• If rectal therapy is chosen, use mesalamine enemas rather than rectal corticosteroids 1
• Patients prioritizing convenience over maximal effectiveness may reasonably choose oral mesalamine 1

Proctitis (Rectal Disease Only)

• Mesalamine suppositories (1 gram once daily) are the most effective initial treatment for ulcerative proctitis 1, 3
• This is a strong recommendation with moderate-quality evidence 1
• Suppositories deliver medication more effectively to the rectum than enemas 3
• Mesalamine foam or enemas (at least 1g daily) are effective alternatives if suppositories cannot be tolerated 3

Dose Escalation for Suboptimal Response

If patients have suboptimal response to standard-dose therapy or present with moderate disease activity, escalate to high-dose mesalamine (>3 grams/day) combined with rectal mesalamine. 1

• High-dose oral mesalamine (>3g/day) is more effective than standard doses for moderate disease 1
• The combination of oral plus rectal therapy is more effective than either alone 1
• No dose-response benefit has been observed above 1 gram daily for topical therapy 3

Management of Refractory Disease

When 5-ASA Therapy Fails

For patients refractory to optimized oral and rectal 5-ASA therapy (regardless of disease extent), add either oral prednisone or budesonide MMX. 1

• This applies to all disease locations when maximal 5-ASA therapy has failed 1
• Evaluate response to mesalamine therapy within 4-8 weeks to determine if treatment modification is needed 3
• Treatment failure is defined as inability to achieve corticosteroid-free remission despite optimal 5-ASA therapy 3

For Mesalamine-Intolerant Patients

• In patients intolerant of or refractory to mesalamine suppositories, use rectal corticosteroid therapy 1, 3
• Rectal corticosteroid foam preparations may be preferred by patients who have difficulty with mesalamine enemas 1, 3

Therapies NOT Recommended in Primary Care

Do not recommend probiotics, curcumin, or fecal microbiota transplantation for mild-to-moderate ulcerative colitis outside of clinical trials 1

• The AGA makes no recommendation for probiotics or curcumin due to insufficient evidence 1
• Fecal microbiota transplantation should only be performed in clinical trial contexts 1

Medication Formulations and Practical Considerations

Available 5-ASA Formulations

• Mesalamine preparations: Delayed-release enteric-coated tablets (Asacol), controlled-release (Pentasa), MMX formulation (Lialda), delayed enteric-coated granules (Apriso) 1
• Diazo-bonded 5-ASA: Olsalazine (Dipentum), Balsalazide (Colazal) - prodrugs converted to 5-ASA in the colon 1
• Sulfasalazine: May be considered for patients already in remission on this agent or those with prominent arthritic symptoms when alternatives are cost-prohibitive, though it has higher intolerance rates 1

Dosing Definitions

• Low dose: <2 grams/day of mesalamine 1
• Standard dose: 2-3 grams/day of mesalamine 1
• High dose: >3 grams/day of mesalamine 1

Monitoring Requirements

Monitor renal function periodically in all patients on 5-ASA therapy 1

• Rare but serious adverse effects include interstitial nephritis 1
• Other rare adverse effects include idiosyncratic worsening of colitis (presumed hypersensitivity syndrome) and secretory diarrhea (primarily with olsalazine) 1
• Patients with UC require monitoring of symptoms and biomarkers of inflammation (e.g., fecal calprotectin) 4
• Colonoscopy surveillance for dysplasia should begin at 8 years from diagnosis 4

Common Pitfalls to Avoid

• Do not switch between different oral 5-ASA formulations when initial therapy fails - instead, escalate dose or add rectal therapy 3
• Do not use rectal corticosteroids as first-line therapy instead of mesalamine suppositories for proctitis 3
• Do not fail to evaluate response within 4-8 weeks - early assessment allows timely treatment modification 3
• Do not use budesonide MMX or controlled ileal-release budesonide as first-line therapy instead of standard-dose mesalamine 1
• Avoid rectal suppositories and enemas in patients with suspected mechanical bowel obstruction 5

When to Refer to Gastroenterology

• Failure to achieve remission with optimized 5-ASA therapy (oral plus rectal) within 8 weeks 3
• Need for corticosteroid therapy beyond induction (patients requiring maintenance corticosteroids) 4
• Moderate-to-severe disease requiring biologic therapy or small molecule inhibitors 4
• Presence of extraintestinal manifestations such as primary sclerosing cholangitis 4
• Any patient requiring hospitalization or at risk for colectomy 4