What are the treatment options for colitis?

Treatment of Colitis

For mild to moderate ulcerative colitis, start with mesalamine 2.4-4.8 grams daily combined with topical mesalamine (1g suppository for proctitis or enema for left-sided disease), escalating to oral prednisolone 40mg daily if inadequate response after 2-4 weeks, and reserve biologics (infliximab or vedolizumab) for moderate-severe disease or early use in patients at high risk of colectomy. 1, 2

Initial Treatment Strategy Based on Disease Location

Proctitis (Rectum Only)

• Mesalamine 1g suppository once daily is the preferred first-line treatment, as suppositories deliver drug more effectively to the rectum than foam or enemas and are better tolerated. 2
• Topical mesalamine is superior to topical corticosteroids for proctitis. 2
• Combining topical mesalamine with oral mesalamine (≥2.4g daily) increases effectiveness over either alone. 2, 1
• If refractory to topical therapy, escalate to systemic corticosteroids, immunosuppressants, or biologics. 2

Left-Sided Colitis

• Combine oral mesalamine 2-4g daily with topical mesalamine 1g enema daily for optimal efficacy. 1, 3
• Once-daily dosing is as effective as divided doses and may improve adherence. 1
• Topical formulation selection: use liquid enemas for disease extending beyond the rectum. 1

Extensive/Pancolitis

• Start with oral mesalamine 2.4-4.8g daily (higher doses are more effective than standard 2-3g dosing). 1, 3, 4
• Add topical mesalamine enemas 1g daily for troublesome rectal symptoms. 5
• Combination oral plus topical therapy is more effective than either alone. 5

Escalation for Inadequate Response to Aminosalicylates

Moderate Disease Not Responding to 5-ASA

• Initiate oral prednisolone 40mg daily if insufficient response to optimized mesalamine therapy after 2-4 weeks. 1, 5
• Taper prednisolone gradually over approximately 8 weeks according to patient response. 1, 5
• Topical agents may be continued as adjunctive therapy with systemic corticosteroids. 5

Steroid-Dependent Disease

• Use azathioprine 1.5-2.5mg/kg/day or mercaptopurine 0.75-1.5mg/kg/day for patients requiring repeated steroid courses or unable to taper steroids. 1, 5
• Avoid long-term steroid treatment due to significant side effects. 5

Moderate to Severe Disease Requiring Advanced Therapy

Biologic-Naïve Patients

• Infliximab or vedolizumab are preferred first-line biologic options over standard-dose adalimumab or golimumab based on network meta-analysis. 2
• Infliximab dosing: 5mg/kg IV at weeks 0,2, and 6, then every 8 weeks for maintenance. 6
• For patients who respond initially then lose response, consider increasing infliximab to 10mg/kg. 6
• Patients who do not respond by week 14 are unlikely to respond with continued dosing and should discontinue. 6

Prior Infliximab Exposure

• Vedolizumab or tofacitinib are preferred over adalimumab or golimumab, particularly in patients with primary non-response to infliximab induction. 2

Combination vs. Monotherapy

• Combination therapy of a biologic with an immunomodulator is more effective than monotherapy with either agent alone. 2
• Patients with less severe disease or those averse to medication side effects may opt for monotherapy after shared decision-making. 2

Early Biologic Use

• In patients at high risk of colectomy, use biologics with or without immunomodulators (or tofacitinib) early rather than gradual step-up after 5-ASA failure. 2

Acute Severe Ulcerative Colitis (ASUC)

Hospital Management

• Admit all patients with severe disease (bloody stools ≥6/day plus tachycardia >90/min, fever >37.8°C, hemoglobin <10.5g/dL, or ESR >30mm/h). 2
• Requires joint management by gastroenterologist and colorectal surgeon. 5

Medical Treatment

• Intravenous methylprednisolone 40-60mg/day is the mainstay of therapy. 2
• Do not routinely use adjunctive antibiotics in patients without documented infections. 2
• For patients refractory to 3-5 days of IV corticosteroids who prefer ongoing medical management, treat with either infliximab or cyclosporine. 2

Supportive Care

• IV fluid and electrolyte replacement. 5
• Blood transfusion to maintain hemoglobin >10g/dL. 5
• Subcutaneous heparin for thromboembolism prophylaxis. 5
• Nutritional support if malnourished. 5

Maintenance Therapy

Long-Term Management

• Lifelong maintenance therapy is recommended for all patients with left-sided or extensive disease. 1, 3
• Aminosalicylates are effective and safe for maintenance. 1, 3
• Patients in remission on biologics and/or immunomodulators after prior 5-ASA failure may discontinue aminosalicylates. 2

Critical Pitfalls to Avoid

• Do not use thiopurine monotherapy for induction of remission (only for maintenance). 2
• Do not use methotrexate (oral or subcutaneous) for induction or maintenance of UC remission. 2
• Avoid antidiarrheal medications as they can mask worsening symptoms while allowing inflammation to progress and may predispose to toxic megacolon. 5
• Screen and treat latent tuberculosis before starting infliximab due to risk of reactivation and serious infections. 6
• Monitor for hepatosplenic T-cell lymphoma risk in adolescent/young adult males receiving TNF-blockers with concomitant azathioprine or mercaptopurine. 6
• Sulfasalazine has higher side effect rates compared to newer mesalamine formulations; prefer mesalamine, balsalazide, or olsalazine. 1, 5