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 choice of mesalamine suppositories is based on the highest quality and most recent evidence available, specifically from the 2019 AGA clinical practice guidelines on the management of mild-to-moderate ulcerative colitis 1.
- For patients who are intolerant of or refractory to mesalamine suppositories, rectal corticosteroid therapy is suggested as an alternative, although this is based on conditional recommendation and low quality evidence 1.
- The use of probiotics or curcumin in patients with mild-moderate ulcerative colitis is not recommended due to a knowledge gap in the current evidence 1.
- Fecal microbiota transplantation is only recommended in the context of a clinical trial for patients without Clostridium difficile infection, highlighting the need for further research in this area 1.
Treatment Approach
- Mesalamine suppositories (1g daily) are the preferred initial treatment for mild or moderately active proctitis, as supported by ECCO statement 11A, which suggests that mesalamine suppositories deliver the drug more effectively to the rectum and are better tolerated than alternatives 1.
- Combining topical mesalamine with oral mesalamine or topical steroids may be considered for more effective management, based on the available evidence 1.
- Refractory proctitis may require escalation to systemic steroids, immunosuppressants, and/or biologics, as indicated by ECCO statement 11B, although this approach is based on lower levels of evidence 1.
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