What are the treatment options for microscopic colitis?

From the Guidelines

Budesonide is the recommended first-line treatment for microscopic colitis, as it has been shown to be effective in inducing clinical remission with a strong recommendation and moderate to high quality of evidence 1.

Treatment Overview

The treatment of microscopic colitis typically involves a step-wise approach, starting with lifestyle modifications and medications to reduce inflammation and control symptoms.

• The goal of treatment is to induce and maintain clinical remission, improve quality of life, and minimize the risk of complications.
• Budesonide, an oral corticosteroid, is the most effective medication for inducing clinical remission in patients with microscopic colitis, with a strong recommendation and moderate to high quality of evidence 1.

First-Line Treatment

• Budesonide is the preferred first-line treatment for microscopic colitis, with a dose of 6-9 mg daily for 6-8 weeks, followed by gradual tapering 1.
• Budesonide has been shown to be effective in inducing clinical remission, with a 66% lower relative risk of clinical relapse compared to no treatment 1.

Alternative Treatments

• For patients who do not respond to budesonide or in whom budesonide therapy is not feasible, mesalamine may be considered as an alternative treatment, with a conditional recommendation and moderate quality of evidence 1.
• Other treatments, such as prednisolone or prednisone, may be considered in severe cases or in patients who have refractory symptoms after treatment, but the quality of evidence for these treatments is very low 1.

Maintenance Therapy

• For patients who experience a recurrence of symptoms after discontinuation of induction therapy, maintenance therapy with budesonide may be considered, with a strong recommendation and moderate quality of evidence 1.
• The goal of maintenance therapy is to prevent clinical relapse and maintain quality of life, with a dose of 3-6 mg daily 1.

From the FDA Drug Label

Budesonide extended-release tablets are a prescription corticosteroid medicine used to help get active mild to moderate ulcerative colitis (UC) under control (induce remission).

The FDA drug label does not answer the question about the treatment for microscopic colitis, as it specifically discusses the use of budesonide extended-release tablets for ulcerative colitis (UC), not microscopic colitis.

From the Research

Treatment Options for Microscopic Colitis

• The approach to treatment is similar for both lymphocytic colitis and collagenous colitis and should be guided by the severity of the patient's symptoms 2.
• Offending medications highly associated with microscopic colitis should be eliminated as clinically possible 2, 3.
• In patients with mild symptoms, antidiarrheals such as loperamide are the initial choice 2, 3.
• For moderate-severe disease, budesonide is recommended for induction of clinical remission 2, 3, 4, 5, 6.
• In those with recurrent symptoms, low-dose budesonide may be required for maintenance therapy with close monitoring for potential adverse effects 2.
• In rare cases, immunomodulators may be required 2, 3, 5.
• Other treatment options include cholestyramine, bismuth salicylate, antibiotics, probiotics, aminosalicylates, and anti-tumor necrosis factor-alpha inhibitors 3.

Comparison of Treatment Options

• Budesonide has been found to be more effective than mesalamine in inducing clinical remission in patients with microscopic colitis, especially after 8 weeks of follow-up 5.
• Budesonide also showed a lower incidence of adverse events compared to mesalamine 5.
• Budesonide is the only treatment proven in randomized-controlled trials to be effective and safe for induction and maintenance of remission 4, 6.

Management of Microscopic Colitis

• Management of microscopic colitis involves counseling the patient about decreasing their risk factors, such as discontinuing smoking and avoiding medications with suspected association 3.
• The treatment goal is to reduce the number of bowel movements and improve consistency 3.
• A systematic stepwise approach for relapsing and refractory disease is needed, and more research is required to create such an approach 3.