What is the most appropriate therapy for a 16-year-old boy with a 3-week history of diarrhea (loose stools), occasional bloody stools, crampy abdominal pain, fatigue, and weight loss, diagnosed with inflammatory bowel disease (IBD) based on colonoscopy and biopsy findings?

From the Guidelines

The most appropriate therapy for this 16-year-old boy is mesalamine therapy (option C). This patient is presenting with symptoms consistent with ulcerative colitis, including bloody diarrhea, abdominal pain, fatigue, and weight loss. The colonoscopy findings of friable, inflamed rectal mucosa that bleeds easily, along with confirmatory biopsy, are classic for ulcerative colitis. Mesalamine (5-aminosalicylic acid) is the first-line therapy for mild to moderate ulcerative colitis, particularly when the disease is limited to the rectum and distal colon, as supported by the guidelines for the management of inflammatory bowel disease in adults 1.

Some key points to consider in the management of this patient include:

• The use of mesalamine has a favorable safety profile compared to other options like corticosteroids or immunomodulators, making it appropriate as initial therapy, especially in a young patient 1.
• If the patient does not respond adequately to mesalamine within 2-4 weeks, therapy may need to be escalated to include corticosteroids, immunomodulators, or biologics like infliximab, as suggested by the guidelines 1.
• Exclusive enteral nutrition using liquid nutrition formulations is an effective therapy for induction of clinical remission and endoscopic response in Crohn’s disease, but the current patient's diagnosis is more consistent with ulcerative colitis, making mesalamine a more appropriate initial choice 1.
• A Mediterranean diet rich in a variety of fresh fruits and vegetables, monounsaturated fats, complex carbohydrates, and lean proteins and low in ultraprocessed foods, added sugar, and salt is recommended for overall health and general well-being in patients with IBD, but this does not replace the need for specific medical therapy like mesalamine in active disease 1.

Given the patient's presentation and the evidence available, mesalamine therapy is the most appropriate initial treatment, with the possibility of escalation to other therapies if there is an inadequate response, always prioritizing the patient's morbidity, mortality, and quality of life as the outcome.

From the Research

Diagnosis and Treatment

The patient's symptoms, including loose stools, bloody stools, crampy abdominal pain, and weight loss, are consistent with ulcerative colitis (UC) 2, 3, 4, 5, 6. The colonoscopy and biopsy results confirm the diagnosis of UC.

Treatment Options

The following treatment options are available for UC:

• Mesalamine therapy: Mesalamine is a 5-aminosalicylic acid compound that is the first-line therapy to induce and maintain clinical remission in patients with mild-to-moderate UC 2, 4, 5.
• Infliximab therapy: Infliximab is effective for treatment of moderate-to-severe UC and is recommended for patients who have had an inadequate response to medical therapy or who are intolerant of or do not desire to take the potential risk of using specific agents 3, 6.
• Prednisone therapy: Prednisone may be used to induce remission in patients with UC, but it is not a first-line treatment 2.
• Proctocolectomy: Proctocolectomy is a surgical option for patients with severe UC who do not respond to medical therapy 6.
• Gluten-free diet: A gluten-free diet is not a treatment for UC, as UC is not caused by gluten sensitivity 2, 3, 4, 5, 6.
• Cyclosporine therapy: Cyclosporine may be used to treat severe UC, but it is not a first-line treatment 2, 3.

Most Appropriate Therapy

Based on the patient's symptoms and diagnosis, the most appropriate therapy is:

• Mesalamine therapy: The patient has mild-to-moderate UC, and mesalamine is the first-line therapy for this condition 2, 4, 5. Alternatively, if the patient does not respond to mesalamine therapy, infliximab therapy may be considered 3, 6.