What is the treatment for lymphocytic colitis?

Treatment of Lymphocytic Colitis

Budesonide 9 mg daily for 6-8 weeks is the first-line pharmacologic treatment for lymphocytic colitis, achieving clinical response in approximately 88% of patients. 1

Initial Management Steps

Eliminate Triggering Factors

• Discontinue NSAIDs immediately if the patient is taking them, as these medications are strongly associated with increased incidence of microscopic colitis 2, 3
• Stop other potentially causative medications including proton pump inhibitors, ranitidine, and sertraline when possible 4
• Eliminate dietary secretagogues such as caffeine and lactose-containing foods 3
• Counsel patients to stop smoking if applicable 4

Rule Out Infectious Causes

• Obtain stool cultures, C. difficile testing, and evaluation for parasites and viral pathogens at initial presentation before starting treatment 2

Pharmacologic Treatment Algorithm

First-Line Therapy: Budesonide

• Start budesonide 9 mg daily for 6-8 weeks as the primary treatment 1
• This achieves clinical response in 88% of patients compared to 38% with placebo (RR 2.03,95% CI 1.25-3.33) 1
• Histological response occurs in 78% versus 33% with placebo (RR 2.44,95% CI 1.13-5.28) 1
• Budesonide is preferred over systemic corticosteroids due to its favorable side effect profile 4
• Common adverse effects include nausea, vomiting, neck pain, abdominal pain, hyperhidrosis, and headache 1

Important caveat: Relapse rates after budesonide discontinuation are high, and many patients require long-term maintenance therapy 4

Adjunctive Symptomatic Therapy

• Start loperamide 4 mg initially, followed by 2 mg every 2-4 hours (maximum 16 mg/day) for immediate symptomatic relief 5
• Loperamide can be used concurrently with budesonide as adjunctive therapy 5
• Monitor for cardiac adverse reactions, especially at higher doses 5
• Alternative antidiarrheal agents include diphenoxylate/atropine, deodorized tincture of opium, or codeine 3, 6

Second-Line Options for Budesonide-Refractory Disease

Bismuth Subsalicylate:

• Use 8 chewable 262-mg tablets daily (approximately 2.1 grams total) 3
• Achieves symptom control in approximately 50% of patients 3
• Well-tolerated with minimal adverse effects 6

Mesalazine (5-ASA compounds):

• Dose: 2.4 grams daily 1
• Clinical response occurs in approximately 85% of patients 1
• Adding cholestyramine 4 g/day to mesalazine does not improve response rates (86% vs 85%) 1
• Preferred for patients with sulfa allergy or adverse reactions to sulfasalazine 3
• Adverse effects include nausea and skin rash 1

Beclometasone dipropionate:

• Dose: 5-10 mg daily 1
• Achieves clinical remission in 84% at 8 weeks, comparable to mesalazine (86%) 1
• However, remission is poorly maintained at 12 months (26% vs 20% with mesalazine) 1
• Adverse effects include nausea, sleepiness, and mood changes 1

Additional Considerations for Specific Presentations

If steatorrhea is documented:

• Implement a low-fat diet 3

If bile salt malabsorption is present:

• Add cholestyramine as a bile acid sequestrant 3

Third-Line Options for Refractory Disease

Systemic corticosteroids:

• Reserve for patients unable to take budesonide 4
• Achieves resolution of diarrhea in 80-90% of patients within 1 week 3
• Most patients require long-term therapy to maintain remission 3

Antibiotics:

• Metronidazole or erythromycin achieve response rates of approximately 60% 3

Immunomodulators and biologics:

• Consider for glucocorticoid-refractory disease 4
• Anti-TNF agents may be used in severe refractory cases 4

Surgical Management

• Reserve colectomy with ileostomy for patients with disease completely refractory to all medical therapy 3
• Small case series show clinical and histologic resolution after surgery 3

Common Pitfalls

• Do not delay treatment while waiting for stool culture results if clinical suspicion is high 2
• Recognize that no single therapy produces complete response in more than 40% of patients, so combination approaches are often necessary 6
• Be aware that relapse after treatment discontinuation is common, requiring long-term maintenance strategies 4
• If symptoms persist despite appropriate treatment, rule out alternative diagnoses including thyroid dysfunction, celiac disease, or bacterial overgrowth 3