From the Guidelines
For patients with mild-to-moderate ulcerative proctitis, the most effective treatment is mesalamine suppositories, as recommended by the AGA guidelines 1. This approach is supported by the highest quality evidence available, which emphasizes the importance of using mesalamine suppositories for patients who choose rectal therapy over oral therapy. The key points to consider in the treatment of proctocolitis include:
- The use of mesalamine suppositories as the first-line treatment for mild-to-moderate ulcerative proctitis, with a strong recommendation and moderate quality evidence 1.
- The consideration of rectal corticosteroid therapy for patients who are intolerant of or refractory to mesalamine suppositories, although this is based on conditional recommendation and low quality evidence 1.
- The importance of avoiding repeated courses of corticosteroids and considering escalation of therapy in patients who frequently need corticosteroids for disease control 1.
- The role of oral mesalamine, which can be added for more extensive disease, with standard-dose mesalamine being recommended for patients with extensive mild-to-moderate UC 1. Some other treatment options that may be considered include:
- Corticosteroid enemas, such as hydrocortisone, for flares 1.
- Immunomodulators, such as azathioprine, or biologics, such as infliximab, for severe cases 1.
- Supportive care, including hydration, anti-diarrheals, and dietary modifications, to manage symptoms and prevent complications 1. It is essential to note that the treatment effectiveness varies based on the cause of proctocolitis, with most infectious cases resolving completely, while inflammatory conditions often require long-term management to prevent recurrence and complications. The European evidence-based consensus on diagnosis and management of ulcerative colitis also supports the use of mesalamine suppositories as the preferred initial treatment for mild or moderately active proctitis, with a high level of evidence [EL1] 1.
From the FDA Drug Label
The mechanism of action of mesalamine is not fully understood, but it appears to have a topical anti-inflammatory effect on the colonic epithelial cells
- Treatment for proctocolitis: Mesalamine has a topical anti-inflammatory effect on the colonic epithelial cells, which may be beneficial in treating proctocolitis.
- Key points:
- Mesalamine appears to have a topical anti-inflammatory effect on the colonic epithelial cells.
- The exact mechanism of action is not fully understood.
- Mesalamine may diminish inflammation by blocking cyclooxygenase and inhibiting prostaglandin production in the colon. 2
From the Research
Treatment Options for Proctocolitis
- Topical aminosalicylates are effective first-line agents in ulcerative proctitis and distal UC, acting more effectively and rapidly to induce and maintain remission compared to oral counterparts or topical steroids 3, 4, 5, 6
- Topical 5-ASA is superior to placebo for induction and maintenance of clinical remission, and for induction of endoscopic remission 5, 6
- Combination of topical and oral 5-ASA and steroids should be considered for escalation of treatment 4
- Systemic corticosteroids, antibiotics, immunomodulators, or surgery may be required in cases of refractory ulcerative proctitis 3, 7
- Immunomodulators have an important role in individuals with glucocorticoid-dependent or glucocorticoid-refractory disease 7
Pharmacological Agents for Ulcerative Proctitis
- 5-Aminosalicylic acid (5-ASA) suppository is the most frequently evaluated treatment for ulcerative proctitis, demonstrating effectiveness for induction of clinical response or remission and prevention of relapse 6
- Combined topical steroids and 5-ASA is more effective than topical 5-ASA or topical steroids alone to induce response 6
- Azathioprine may be effective in patients with ulcerative proctitis, according to observational studies 6
- Tumour necrosis factor inhibitors have been evaluated in only two cohort studies, with limited evidence for their efficacy in ulcerative proctitis 6