What is the best management approach for a patient with chronic colitis?

Management of Chronic Colitis

For chronic colitis management, initiate treatment based on disease extent and severity: use combination topical mesalazine 1g daily plus oral mesalazine 2-4g daily for distal disease, oral mesalazine 2-4g daily or prednisolone 40mg daily for extensive disease, and establish lifelong maintenance therapy with aminosalicylates to prevent relapse and reduce colorectal cancer risk. 1, 2

Initial Assessment and Classification

Before initiating therapy, confirm disease activity by sigmoidoscopy and exclude infectious causes, though treatment should not be delayed awaiting stool culture results 1, 3. Classify disease by anatomic extent:

• Distal colitis: Disease up to the sigmoid-descending junction, including proctitis (rectum only) 1
• Left-sided disease: Extends from sigmoid-descending junction to splenic flexure 1
• Extensive disease: Extends proximal to the splenic flexure 1

Treatment Algorithm by Disease Location

Distal Colitis (Proctitis and Left-Sided Disease)

First-line therapy requires combination treatment, which is superior to monotherapy 2:

• Topical mesalazine 1g daily (suppositories for proctitis, foam or liquid enemas for more proximal disease) PLUS oral mesalazine 2-4g daily 1, 2
• Alternative oral agents: olsalazine 1.5-3g daily or balsalazide 6.75g daily 1

Second-line therapy for patients failing combination aminosalicylates 1:

• Oral prednisolone 40mg daily, with topical agents continued as adjunctive therapy 1, 2
• Taper prednisolone gradually over 8 weeks; rapid reduction causes early relapse 1, 2

Important caveat: Topical corticosteroids are less effective than topical mesalazine and should be reserved for patients intolerant of topical mesalazine 1, 2

Extensive or Left-Sided Disease

Mild to moderate disease 1:

• Mesalazine 2-4g daily or balsalazide 6.75g daily as first-line therapy 1
• Olsalazine 1.5-3g daily has higher diarrhea incidence in pancolitis; reserve for left-sided disease or mesalazine intolerance 1

Moderate to severe disease or failed aminosalicylate therapy 1:

• Prednisolone 40mg daily, tapered gradually over 8 weeks 1
• For patients requiring prompt response, initiate prednisolone immediately 1

Biologic therapy considerations 1:

• The 2020 AGA guidelines suggest early use of biologic agents (TNF-α antagonists, vedolizumab, or ustekinumab) with or without immunomodulator therapy rather than gradual step-up after 5-ASA failure, particularly for patients with more severe disease 1
• Combination therapy with biologics plus thiopurines or methotrexate is preferred over biologic monotherapy for improved efficacy 1

Steroid-Dependent Disease

For patients requiring chronic steroid therapy or experiencing frequent relapses 1:

• Azathioprine 1.5-2.5 mg/kg/day or mercaptopurine 0.75-1.5 mg/kg/day 1
• Long-term corticosteroid use is undesirable and should be avoided 1

Severe Colitis Requiring Hospitalization

Severe disease is defined by bloody stool frequency ≥6/day plus tachycardia >90/min, temperature >37.8°C, hemoglobin <10.5 g/dL, or ESR >30 mm/h 2. Management requires 1:

• Joint gastroenterology and colorectal surgery consultation from admission 1, 3
• Intravenous methylprednisolone 40-60mg daily (not higher doses) 1
• Daily physical examination for abdominal tenderness and rebound 1
• Vital signs monitoring four times daily 1
• Laboratory monitoring (CBC, ESR/CRP, electrolytes, albumin) every 24-48 hours 1
• Subcutaneous heparin for thromboprophylaxis 1, 3
• IV fluid and electrolyte replacement, blood transfusion to maintain hemoglobin >10 g/dL 1
• Nutritional support if malnourished 1

For steroid-refractory severe colitis 1:

• Infliximab or cyclosporine are both appropriate rescue therapies 1, 4
• Infliximab dosing: 5mg/kg at weeks 0,2, and 6, then every 8 weeks 4
• Do NOT use adjunctive antibiotics in the absence of documented infection 1

Maintenance Therapy

Lifelong maintenance is recommended for all patients, especially those with left-sided or extensive disease 1, 2:

• Aminosalicylates (mesalazine, balsalazide, or olsalazine) reduce relapse risk and potentially reduce colorectal cancer risk 1, 2
• For patients in remission on biologics and/or immunomodulators, discontinue 5-ASA as it provides no additional benefit 1
• Thiopurine monotherapy may be used for maintenance in steroid-dependent disease 1

Critical Pitfalls to Avoid

• Never use monotherapy when combination therapy is indicated: Topical plus oral aminosalicylates are significantly more effective than either alone for distal disease 2
• Never taper steroids rapidly: Prednisolone must be reduced gradually over 8 weeks to prevent early relapse 1, 2
• Never delay corticosteroids while awaiting stool cultures in suspected severe colitis 3
• Never continue IV corticosteroids beyond 7-10 days without escalating to rescue therapy (infliximab or cyclosporine) or surgery 3
• Screen for latent tuberculosis before initiating infliximab: Perform testing and treat if positive before starting therapy 4
• Monitor for serious infections and malignancies with biologic therapy, particularly hepatosplenic T-cell lymphoma in young males receiving combination therapy with azathioprine or mercaptopurine 4