What are the treatment options for managing colitis symptoms?

Treatment of Colitis Symptoms

For inflammatory bowel disease-related colitis, treatment should be stratified by disease severity and location, with mild-to-moderate distal disease treated with combination topical and oral mesalamine (1g topical + 2-4g oral daily), moderate-to-severe disease requiring oral corticosteroids (prednisolone 40mg daily), and severe disease necessitating intravenous steroids with early consideration of biologic rescue therapy if no improvement by day 3. 1

Initial Assessment and Workup

Before initiating treatment, several critical steps must be completed:

• Rule out infectious causes through stool studies including culture, C. difficile toxin, ova and parasites, and viral pathogens (CMV if immunosuppressed), as treatment with corticosteroids should not be delayed but infectious etiologies alter management 1
• Obtain baseline laboratory studies including CBC, CMP, ESR or CRP, serum albumin, and liver function tests 1
• Consider fecal inflammatory markers (lactoferrin or calprotectin) to stratify patients who need urgent endoscopy and to monitor treatment response 1
• Perform flexible sigmoidoscopy or colonoscopy with biopsies for grade ≥2 symptoms to confirm diagnosis, assess severity, and identify high-risk endoscopic features (ulceration) that predict steroid-refractory disease requiring early biologic therapy 1

Treatment Algorithm by Severity

Mild Disease (Grade 1)

Defined as <4 additional stools per day over baseline, no systemic symptoms 1

• Continue current therapy or hold temporarily if on immune checkpoint inhibitors 1
• Supportive care with hydration, dietary modifications, and loperamide only if infection ruled out and symptoms are diarrhea-only without colitis features 1
• Monitor closely every 3 days by phone or electronic system for symptom progression 1
• For distal ulcerative colitis: Initiate combination therapy with topical mesalamine 1g daily (suppository for rectosigmoid disease, enema for more proximal disease) plus oral mesalamine 2-4g daily 1, 2, 3
• For Crohn's disease: High-dose oral mesalamine 4g daily may be sufficient for mild ileocolonic disease 1

Moderate Disease (Grade 2)

Defined as 4-6 additional stools per day over baseline 1

• Hold immune checkpoint inhibitors if applicable until recovery to grade 1 1
• Initiate corticosteroids at 1 mg/kg/day prednisone (typically prednisolone 40mg daily) until symptoms improve to grade 1, then taper over 4-6 weeks 1
• Obtain gastroenterology consultation for all grade ≥2 cases 1
• Perform endoscopy to identify high-risk features (ulceration, severe inflammation) that warrant early biologic therapy 1
• Add infliximab or vedolizumab if corticosteroid-refractory (no improvement within 72 hours) or if high-risk endoscopic features present 1
• For distal disease: Continue combination topical and oral mesalamine as adjunctive therapy 1

Critical pitfall: Rapid steroid tapering (less than 4-6 weeks) is associated with early relapse and should be avoided 1, 2

Severe Disease (Grade 3-4)

Grade 3: ≥7 additional stools per day, incontinence, limiting self-care; Grade 4: life-threatening 1

• Hospitalize immediately for inpatient management 1
• Joint management by gastroenterologist and colorectal surgeon from admission 1
• Intravenous corticosteroids: Methylprednisolone 60mg every 24 hours or hydrocortisone 100mg four times daily 1
• Supportive care measures:
  • IV fluid and electrolyte replacement (potassium supplementation ≥60 mmol/day to prevent toxic dilatation) 1
  • Blood transfusion to maintain hemoglobin >10 g/dL 1
  • Subcutaneous low-molecular-weight heparin for thromboprophylaxis 1
  • Nutritional support (enteral preferred over parenteral) if malnourished 1
• Daily monitoring:
  • Vital signs four times daily 1
  • Stool chart documenting frequency, character, and blood 1
  • Laboratory studies (CBC, CRP, electrolytes, albumin) every 24-48 hours 1
  • Daily abdominal radiography if colonic dilatation (transverse colon >5.5 cm) present 1

Early biologic rescue therapy (by day 3):

• Consider infliximab or vedolizumab if inadequate response to steroids after 3 days or if high-risk endoscopic features identified 1
• Alternative: Ciclosporin 2 mg/kg/day IV is equally effective as IV steroids and can be used as monotherapy in patients who must avoid steroids (steroid psychosis, severe osteoporosis, uncontrolled diabetes) 1
• Do not extend steroid therapy beyond 7-10 days without improvement, as this increases morbidity without additional benefit 1

Critical decision point: Patients remaining on ineffective corticosteroids beyond day 3-5 suffer high morbidity from delayed surgery; colectomy should be considered early if no response to rescue therapy 1

Steroid-Refractory Disease

For patients not responding to initial corticosteroids and biologics:

• Infliximab is the most established anti-TNF agent for steroid-refractory colitis 1
• Vedolizumab (anti-integrin) provides gut-specific immunosuppression and may theoretically preserve antitumor immunity in checkpoint inhibitor-related colitis 1
• Early introduction (within 10 days of colitis onset) reduces symptom duration and improves steroid taper success 1
• Treatment with ≥3 doses and achieving endoscopic/histologic remission reduces relapse risk 1
• Repeat colonoscopy should be considered for immunosuppression-refractory cases 1
• Fecal microbiota transplantation may be considered for cases resistant to corticosteroids, infliximab, and vedolizumab 1

Special Considerations

Immune Checkpoint Inhibitor-Related Colitis

• Permanently discontinue CTLA-4 agents for grade ≥2 colitis 1
• PD-1/PD-L1 agents may be restarted after recovery to grade ≤1, completion of steroid taper, and ideally achievement of endoscopic/histologic remission (or fecal calprotectin ≤116 mg/g as surrogate) 1
• Avoid topical budesonide for mild disease given lack of efficacy evidence in this context 1

Medications to Avoid

• Withdraw anticholinergic drugs (including hyoscyamine), anti-diarrheal agents, NSAIDs, and opioids during acute severe colitis as they may precipitate toxic megacolon 1, 4
• Loperamide should only be used in grade 1 diarrhea-only cases after infection is ruled out, not in colitis with inflammatory features 1

Constipation in Colitis

• Proximal constipation should be treated with stool bulking agents or laxatives, as this is common in distal colitis 1, 2

Maintenance Therapy

After achieving remission:

• Lifelong maintenance therapy is recommended for all patients, especially those with left-sided or extensive disease 1
• Aminosalicylates (mesalamine 2.4g daily) are first-line for maintenance 1, 3
• Azathioprine 1.5-2.5 mg/kg/day or mercaptopurine 0.75-1.5 mg/kg/day for steroid-dependent or frequently relapsing disease 1, 2
• Maintenance therapy reduces colorectal cancer risk in addition to preventing relapse 1

Monitoring and Follow-up

• Renal function should be assessed before starting mesalamine and periodically during treatment, with discontinuation if deterioration occurs 3
• Complete blood counts should be monitored in patients on azathioprine/mercaptopurine or in geriatric patients due to blood dyscrasia risk 3
• Adequate hydration is essential to prevent nephrolithiasis with mesalamine (mesalamine stones are undetectable by standard radiography) 3
• Endoscopic remission (mucosal healing) is a better predictor of sustained remission than clinical symptoms alone and should guide decisions about resuming checkpoint inhibitors or stopping biologics 1