What is the best course of action for a patient with a history of lymphocytic colitis who has stopped taking Entocort (budesonide) and is now experiencing recurrent symptoms?

Management of Recurrent Lymphocytic Colitis After Stopping Entocort

Restart budesonide for maintenance therapy at 6 mg daily, as this is the AGA's strong recommendation for patients with recurrent symptoms following discontinuation of induction therapy for microscopic colitis. 1

Rationale for Budesonide Maintenance

The American Gastroenterological Association provides a strong recommendation with moderate-quality evidence specifically for this clinical scenario—patients who experience symptom recurrence after stopping budesonide should resume budesonide for maintenance of clinical remission. 1

• Efficacy data: Maintenance budesonide 6 mg daily over 6 months reduces clinical relapse risk by 66% (relative risk 0.34,95% CI 0.19-0.6) compared to no treatment. 1
• This regimen also maintains histological response and quality of life effectively. 1
• A lower alternating dose (3 mg daily alternating with 6 mg daily) over 12 months showed similar efficacy in maintaining clinical response. 1

Practical Implementation

Starting dose: Begin with budesonide 6 mg daily, then taper to the lowest effective dose that controls symptoms. 1

Duration considerations:

• Cessation of maintenance therapy can be considered after 6 to 12 months of treatment. 1
• Up to one-third of patients may not require long-term maintenance therapy after initial treatment. 1
• Real-world data shows that 76% of lymphocytic colitis patients respond well to budesonide as first-line therapy. 2

Critical Monitoring Requirements

Bone health surveillance: Although budesonide has low systemic bioavailability, prolonged use may predispose to bone loss. 1

• Implement osteoporosis prevention strategies in patients requiring maintenance therapy. 1
• Consider bone density screening for patients on long-term budesonide. 1

Drug interactions: If concurrent administration with ketoconazole or any CYP3A4 inhibitor is necessary, monitor closely for signs/symptoms of hypercorticism. 3

• Avoid grapefruit juice, which inhibits CYP3A4. 3
• Consider discontinuation of budesonide or the CYP3A4 inhibitor if hypercorticism develops. 3

Alternative Approaches if Budesonide Not Feasible

If budesonide therapy is not feasible due to contraindications, cost, or patient preference:

Second-line option: Mesalamine 2.4 g/day (conditional recommendation, moderate-quality evidence). 1

• Clinical response rates of 85-86% have been reported in lymphocytic colitis. 4
• Less effective than budesonide but may be adequate for maintenance. 1

Symptomatic management: Loperamide can be used for symptomatic relief at an initial dose of 4 mg followed by 2 mg every 2-4 hours (maximum 16 mg/day). 5

• This is appropriate for mild symptoms but does not address the underlying inflammation. 6

Common Pitfalls to Avoid

Do not use probiotics: The AGA suggests against probiotics for microscopic colitis (conditional recommendation, low-quality evidence) due to uncertain benefit-to-harm balance. 1

Do not add cholestyramine to mesalamine: The AGA suggests against combination therapy with cholestyramine and mesalamine over mesalamine alone. 1

Do not delay restarting therapy: Approximately 25-30% of patients relapse after cessation of therapy, and prompt reinitiation of treatment prevents prolonged symptoms. 7

Disease Course Expectations

• The disease course is variable—some patients experience intermittent symptoms while others have chronic progressive symptoms. 6
• Complete resolution of diarrhea can be achieved in all patients with appropriate therapy. 7
• Long-term cessation of diarrhea occurs in more than 70% of patients with proper management. 7
• Approximately 19% of patients may experience symptom exacerbations during therapy, requiring therapy adjustments. 2