What is the recommended treatment for a patient with inflammatory bowel disease (IBD), specifically ulcerative proctitis, considering their past medical history and demographics, using hydrocortisone suppositories?

Hydrocortisone Suppositories for Ulcerative Proctitis

Hydrocortisone suppositories are second-line therapy for ulcerative proctitis, reserved for patients who fail or cannot tolerate mesalamine suppositories, though mesalamine suppositories remain superior and should be tried first. 1

First-Line Treatment: Why Not Hydrocortisone Initially

• Mesalamine suppositories 1 gram once daily are the preferred first-line therapy for mild to moderate ulcerative proctitis, achieving 81.5-83.8% endoscopic remission rates at 4 weeks compared to 29.7-36.1% with placebo. 1, 2

• Mesalamine suppositories demonstrate superior efficacy to hydrocortisone foam for rectal bleeding (p=0.002) and mucus production (p=0.02), with significantly better endoscopic improvement (p=0.02). 3

• Direct comparison trials show mesalamine suppositories achieve better disease activity reduction than hydrocortisone foam (median DAI of 4 vs 6 at 4 weeks, p=0.02), particularly in proctitis patients. 4

When to Use Hydrocortisone Suppositories

Consider hydrocortisone suppositories only after mesalamine suppository failure or intolerance, as part of a stepwise escalation algorithm. 1

Specific Clinical Scenarios:

• Patients with inadequate response to 1 gram mesalamine suppository after 4 weeks of therapy 1

• Patients who cannot tolerate mesalamine suppositories due to adverse effects (occurs in up to 15% of patients) 1

• Patients who prefer foam formulations over suppositories due to prominent proctitis symptoms causing discomfort with suppository retention 1

Treatment Algorithm for Ulcerative Proctitis

Step 1: Start mesalamine suppository 1 gram once daily (usually at night) 1

Step 2 (if incomplete response at 2-4 weeks): Add oral mesalamine 2-3 grams daily to mesalamine suppository 1

Step 3 (if still incomplete response): Switch to or add corticosteroid suppository (e.g., 5 mg prednisolone or hydrocortisone equivalent) and optimize oral mesalamine to 4-4.8 grams daily 1

Step 4 (if refractory): Oral prednisolone 40 mg once daily, weaning over 6-8 weeks 1

Step 5 (if steroid-refractory): Consider advanced therapies including topical tacrolimus, JAK inhibitors, S1P agonists, or biologic therapy 1

Critical Limitations of Hydrocortisone Suppositories

• No randomized controlled trials exist specifically evaluating corticosteroid suppositories in ulcerative proctitis—evidence is extrapolated from corticosteroid enema/foam studies in proctosigmoiditis (low-quality evidence). 1

• Rectal corticosteroids have never been studied for maintenance therapy and should only be used short-term for induction of remission. 1, 5

• Long-term corticosteroid use (topical or systemic) is ineffective for maintenance and associated with significant adverse effects. 1

Practical Considerations Before Declaring Treatment Failure

Before escalating from mesalamine to hydrocortisone suppositories, verify:

• Medication adherence: Low adherence to rectal mesalamine is the primary reason for treatment failure in ulcerative proctitis. 6

• Proper administration technique: Ensure patients understand correct suppository insertion and timing. 5

• Proximal constipation: Obtain abdominal X-ray to exclude fecal loading, which impairs drug delivery and causes treatment failure. 5

• Correct diagnosis: Exclude infectious proctitis (including sexually transmitted infections), Crohn's disease, solitary rectal ulcer, rectal prolapse, and coexisting irritable bowel syndrome. 1

Dosing and Duration

• Hydrocortisone suppositories or foam: typical dosing based on available formulations (specific suppository doses not well-established in trials) 1

• Duration: Use only for induction (typically 2-4 weeks), then transition to mesalamine for maintenance 1

• Never use corticosteroids for long-term maintenance—this is strongly contraindicated regardless of formulation. 1

Safety Profile

• Second-generation topical corticosteroids (budesonide) have <1% risk of adrenocortical axis suppression compared to conventional corticosteroids. 5

• Short-term topical corticosteroid therapy carries low risk of systemic side effects. 5

• Traditional hydrocortisone suppositories may have higher systemic absorption than newer topical corticosteroids like budesonide or beclomethasone. 1, 7

Maintenance Strategy After Remission

Once remission is achieved with hydrocortisone suppositories:

• Transition to mesalamine suppository 1 gram daily for maintenance 1

• Can reduce frequency to every 2nd or 3rd day, or switch to oral mesalamine to improve adherence 1

• Colorectal cancer risk in isolated proctitis is similar to general population, so some patients may choose on-demand therapy for infrequent flares rather than continuous maintenance. 1