Treatment for Lymphocytic Colitis in Pregnancy
Budesonide 9 mg daily for 6-8 weeks is the first-line treatment for active lymphocytic colitis during pregnancy, as it is safe and effective for inducing clinical remission. 1
First-Line Pharmacologic Management
Budesonide should be initiated at 9 mg daily for 6-8 weeks to induce clinical and histological response in active lymphocytic colitis during pregnancy. 1 This corticosteroid achieves 88% clinical response rates compared to 38% with placebo, and is considered safe throughout pregnancy. 2, 1
- Systemic corticosteroids, including budesonide, are safe during pregnancy and should not be withheld due to pregnancy alone. 3
- The risk of active disease to both mother and fetus far exceeds any theoretical medication risks. 2, 3
Alternative Treatment Options
Mesalamine (2.4 g/day) can be used as an alternative or adjunctive therapy, particularly for patients with milder disease or those who prefer to avoid corticosteroids. 1
- Mesalamine is considered safe during pregnancy with no increased risk of congenital malformations, premature births, stillbirths, spontaneous abortions, or low birth weight. 2
- Clinical response rates with mesalamine reach 85% in lymphocytic colitis. 1
- If using sulfasalazine specifically, supplement with 2 mg folic acid daily starting 3 months before conception and continuing throughout pregnancy to prevent neural tube defects. 3
Beclometasone dipropionate (5-10 mg/day) may be considered as another corticosteroid option, achieving 84% clinical remission rates at 8 weeks. 1
Monitoring Disease Activity During Pregnancy
Check fecal calprotectin at preconception, during each trimester, and after delivery to screen for active disease. 2, 3
- A fecal calprotectin cutoff of 200 mg/mg has a positive predictive value of 67-74% for disease activity. 2
- Flexible sigmoidoscopy (preferred over colonoscopy) should be performed if results will affect management decisions. 2, 3
Imaging Considerations
Use ultrasound or MRI without gadolinium if imaging is needed to evaluate disease extent or rule out other causes of symptoms. 2, 3
- Gadolinium must be avoided during pregnancy. 2, 3, 4
- Intestinal ultrasound can distinguish active from quiescent disease with 84% sensitivity and 98% specificity. 2
Hospitalization and Thromboprophylaxis
Provide anticoagulant thromboprophylaxis during any hospitalization for pregnant patients with lymphocytic colitis, with low-molecular-weight heparin preferred over unfractionated heparin. 3, 4
- Pregnant women with IBD have increased thrombotic risk during hospitalization. 3, 4
- Outpatients with active disease should receive VTE prophylaxis during the third trimester unless contraindicated. 4
Multidisciplinary Care Approach
All pregnant patients with lymphocytic colitis should be managed by a gastroenterologist throughout pregnancy, with consultation from a maternal-fetal medicine specialist if available. 2, 3
- Active disease poses greater risks of preterm birth, low birth weight, and other complications than medication exposure. 2
- Conception during remission and maintaining remission throughout pregnancy are essential goals. 2, 3
Critical Pitfalls to Avoid
- Never discontinue maintenance medications solely due to pregnancy, as active disease poses far greater risks than medications. 3
- Methotrexate is absolutely contraindicated and must be stopped at least 6 months before conception. 2, 3
- Do not delay treatment of active disease, as flares during pregnancy carry high risk of adverse maternal and fetal outcomes. 3
- Avoid fluoroquinolones during pregnancy due to potential fetal risks. 4
- Do not use antiperistaltic agents (such as loperamide) in pregnant women with diarrhea, as they can cause serious side effects including ileus. 4
Breastfeeding Considerations
Budesonide, systemic corticosteroids, and mesalamine use should not influence the decision to breastfeed, as these medications are considered safe during lactation. 3