What is the recommended dosage and treatment regimen for hydrocortisone (cortisol) suppositories in ulcerative proctitis?

Hydrocortisone Suppositories in Ulcerative Proctitis

Hydrocortisone suppositories should be reserved as second-line therapy for ulcerative proctitis only after failure or intolerance to 5-ASA suppositories, not as first-line treatment. 1

First-Line Treatment: 5-ASA Suppositories

Start with 5-ASA (mesalamine) suppositories 1 g once daily at bedtime as first-line therapy for mild to moderate ulcerative proctitis. 1 This represents a strong recommendation based on high-quality evidence from the Toronto Consensus and British Society of Gastroenterology guidelines. 1

• 5-ASA suppositories are superior to hydrocortisone suppositories for inducing remission, with a pooled odds ratio of 1.65 favoring 5-ASA over rectal corticosteroids. 1
• Once-daily dosing (1 g at bedtime) is as effective as divided dosing (500 mg three times daily) and significantly improves patient adherence. 2
• Assess response at 4-8 weeks to determine if therapy modification is needed. 1

When to Use Hydrocortisone Suppositories

Add or switch to hydrocortisone suppositories only when patients fail to respond to or cannot tolerate 5-ASA suppositories. 1

Specific Dosing Regimen:

• Prednisolone 5 mg suppository once daily in the morning while continuing 5-ASA suppositories at bedtime. 1
• Alternative: Hydrocortisone suppositories or budesonide suppositories (2-4 mg) can be used. 1
• Continue oral 5-ASA (2-4.8 g daily) if possible when adding corticosteroid suppositories. 1

Important Caveats:

• No randomized controlled trials exist specifically for hydrocortisone suppositories in proctitis—recommendations are based on indirect evidence from corticosteroid enemas and foam preparations in proctosigmoiditis. 1
• Never use corticosteroid suppositories for maintenance therapy—they have not been studied for this indication and long-term corticosteroid use carries significant adverse effects. 1
• The quality of evidence supporting corticosteroid suppositories is low, whereas 5-ASA suppositories have moderate-quality evidence for induction and low-quality evidence for maintenance. 1

Treatment Algorithm

1. Initial therapy: 5-ASA suppository 1 g once daily at bedtime 1
2. If incomplete response at 2-4 weeks: Add oral 5-ASA 2-3 g daily 1
3. If still inadequate response: Add prednisolone 5 mg suppository in morning while continuing 5-ASA suppository at bedtime 1
4. If refractory to above: Consider oral prednisolone 40 mg daily or escalate to immunomodulators/biologics 1

Before Declaring Treatment Failure

Rule out these common pitfalls before escalating therapy: 1

• Non-adherence to suppository regimen (most common cause)
• Proximal constipation contributing to symptoms
• Incorrect diagnosis (Crohn's disease, solitary rectal ulcer, psoriatic colitis)
• Superimposed infection (C. difficile, cytomegalovirus, sexually transmitted infections)
• Co-existing irritable bowel syndrome
• More extensive disease than initially diagnosed (requires repeat endoscopy)

Maintenance Therapy

Continue 5-ASA suppositories 1 g daily for maintenance after achieving remission. 1 Frequency can be reduced to every 2nd or 3rd day to improve long-term adherence, though daily dosing is most effective. 1 Patients with infrequent flares may use suppositories on-demand rather than continuous maintenance, as colorectal cancer risk in isolated proctitis equals the general population. 1

Never use hydrocortisone or other corticosteroid suppositories for maintenance therapy—they are ineffective for this indication and associated with significant adverse effects with prolonged use. 1