From the Guidelines
Enterocolitis treatment should prioritize the use of infliximab or vedolizumab as second-line immunosuppressants for patients who do not respond to high-dose glucocorticoids within 72 hours of initiation or do not have a complete response within a week, as recommended by the AGA clinical practice update on diagnosis and management of immune checkpoint inhibitor colitis and hepatitis: expert review 1.
Treatment Approach
The treatment approach for enterocolitis involves a combination of supportive care and targeted interventions.
- Initial treatment includes fluid and electrolyte replacement through IV therapy to address dehydration, along with bowel rest by temporarily stopping oral intake.
- Antibiotics are prescribed for bacterial causes, with common choices including metronidazole (500mg three times daily), ciprofloxacin (500mg twice daily), or a combination for 7-10 days.
- For Clostridium difficile enterocolitis, oral vancomycin (125mg four times daily) or fidaxomicin (200mg twice daily) for 10-14 days is recommended.
- Anti-inflammatory medications like mesalamine (2-4g daily) may help reduce intestinal inflammation.
- Antidiarrheal agents such as loperamide (2mg after each loose stool, maximum 16mg daily) can provide symptomatic relief once infection is ruled out.
- Probiotics containing Lactobacillus or Saccharomyces boulardii help restore gut flora.
Second-Line Immunomodulators
For patients who do not respond to initial treatment, second-line immunomodulators such as infliximab and vedolizumab are recommended 1.
- Infliximab is typically dosed at 5 mg/kg given intravenously and vedolizumab is given intravenously at a 300-mg dose.
- Both infusions are typically given at weeks 0,2, and 6, with a minority of patients receiving longer-term treatment.
Considerations for Treatment
The decision to choose one biologic therapy over the other should be based on other risk factors, including the underlying malignancy and comorbidities, risk of infection, expected duration of treatment, and other concurrent immune-related adverse events 1.
- Infliximab should be avoided in patients with underlying hematologic malignancies because tumor necrosis factor–a inhibitors are associated with the development of rare lymphomas, and should be used with caution in patients with underlying severe congestive heart failure.
- Vedolizumab may interfere with ongoing antitumor responses in the GI mucosa in patients receiving immunotherapy for primary GI malignancies or for tumors with GI metastases.
From the FDA Drug Label
RENFLEXIS is a tumor necrosis factor (TNF) blocker indicated for: Crohn's Disease: • reducing signs and symptoms and inducing and maintaining clinical remission in adult patients with moderately to severely active disease who have had an inadequate response to conventional therapy. • reducing the number of draining enterocutaneous and rectovaginal fistulas and maintaining fistula closure in adult patients with fistulizing disease.
The treatment for enterocolitis is not directly mentioned in the label. However, Crohn's Disease, which can cause enterocolitis, is an indicated use for infliximab (IV). The recommended dosage for Crohn's Disease is 5 mg/kg at 0,2 and 6 weeks, then every 8 weeks 2.
- Key points:
- Infliximab (IV) is indicated for reducing signs and symptoms of Crohn's Disease.
- The dosage for Crohn's Disease is 5 mg/kg at 0,2 and 6 weeks, then every 8 weeks.
- Enterocolitis treatment is not directly mentioned, but it may be related to the treatment of Crohn's Disease.
From the Research
Enterocolitis Treatment Overview
- Enterocolitis is a condition characterized by inflammation of the small intestine and colon, which can be caused by infectious or non-infectious factors.
- The treatment of enterocolitis depends on the underlying cause, with most forms of infectious colitis being treatable with antimicrobials 3, 4.
Infectious Colitis Treatment
- Standard stool culture should be performed in patients with infectious colitis to determine the causative pathogen 4.
- Once the laboratory diagnosis is made, pathogen-specific antimicrobial therapy should be initiated for all forms of infectious colitis other than Shiga toxin-producing Escherichia coli (STEC) 4.
- For empiric treatment of febrile dysenteric diarrhea, invasive bacterial enteropathogens such as Shigella, Salmonella, and Campylobacter should be suspected, and adults may be treated empirically with 1000mg azithromycin in a single dose 4.
Inflammatory Bowel Disease (IBD) Treatment
- The use of anti-bacterial agents as ancillary treatment in patients with ulcerative colitis or Crohn's disease has been explored, with metronidazole or ciprofloxacin being commonly used antibiotics 5.
- Long-term treatment of ulcerative colitis with ciprofloxacin has shown promising results, with a prospective, double-blind, placebo-controlled study demonstrating improved outcomes in patients responding poorly to conventional therapy 6.
- The pharmacological management of IBD has evolved over the past century, with current treatment options including 5-aminosalicylates, corticosteroids, immunomodulators, biologics, and antibiotics 7.