From the Guidelines
The treatment for proctitis, specifically for mild-moderate ulcerative proctitis, is mesalamine suppositories, as recommended by the AGA with strong recommendation and moderate quality evidence. This approach prioritizes the reduction of morbidity, mortality, and improvement of quality of life for patients.
Key Considerations
- The use of mesalamine suppositories is preferred due to their effectiveness in delivering the drug directly to the rectum and being better tolerated [ 1 ].
- For patients who are intolerant of or refractory to mesalamine suppositories, rectal corticosteroid therapy is suggested as an alternative for induction of remission, although this is based on conditional recommendation and low quality evidence [ 1 ].
- The European evidence-based consensus also supports the use of mesalamine 1-g suppository once daily as the preferred initial treatment for mild or moderately active proctitis [ 1 ].
Treatment Approach
- Mesalamine suppositories (1g daily) are the first-line treatment for inflammatory bowel disease-related proctitis.
- Oral mesalamine (2-4g daily) may be combined with mesalamine suppositories for enhanced efficacy.
- Corticosteroid suppositories or enemas may be added for more severe cases of proctitis.
- Supportive care, including sitz baths, increased fluid intake, and stool softeners, is crucial to reduce discomfort and prevent complications.
Important Notes
- The choice of treatment should be guided by the underlying cause of proctitis, with infectious proctitis requiring antibiotics tailored to the specific pathogen, and radiation or chemical proctitis managed accordingly.
- Treatment should continue until symptoms resolve completely, which may take 2-6 weeks depending on severity and cause, with the goal of preventing complications like strictures or fistulas and improving quality of life.
From the Research
Treatment Options for Proctitis
The treatment for proctitis depends on the underlying cause, with different approaches for ulcerative proctitis and infectious proctitis.
- For ulcerative proctitis, the mainstay of treatment includes:
- Topical aminosalicylates, which are effective for induction and maintenance of remission 2, 3, 4, 5
- Topical corticosteroids, which can be used for induction of remission 3, 4, 5
- Combination therapy with topical 5-ASA and topical corticosteroids, which may be more effective than monotherapy 4, 5
- Oral aminosalicylates, which can be used for maintenance of remission 2, 3
- Systemic corticosteroids, immunomodulators, or surgery may be required for refractory cases 2, 3
- For infectious proctitis, treatment depends on the causative pathogen, with antibiotics or antivirals used as appropriate 6
Pharmacological Agents
Several pharmacological agents have been studied for the treatment of ulcerative proctitis, including:
- 5-Aminosalicylic acid (5-ASA) suppositories, which are effective for induction and maintenance of remission 4, 5
- Topical corticosteroids, such as beclomethasone, which can be used for induction of remission 4
- Azathioprine, which may be effective in patients with ulcerative proctitis 4
- Tumour necrosis factor inhibitors, which have been evaluated in a limited number of studies 4
- Small molecules, anti-integrins, and anti-interleukin therapies, which have not been extensively studied in ulcerative proctitis 4
Treatment Goals
The goals of treatment for proctitis include:
- Induction of remission, which can be achieved with topical 5-ASA, topical corticosteroids, or combination therapy 3, 4, 5
- Maintenance of remission, which can be achieved with topical 5-ASA, oral aminosalicylates, or other agents 2, 3, 5
- Prevention of disease progression, which is an important long-term goal in the management of ulcerative proctitis 3