Collagenous and Lymphocytic Colitis Medication
- Author: Eric Goosenberg, MD; Chief Editor: Julian Katz, MD more...
Medication Summary
Medication is indicated only if discontinuing dietary components or medications considered possibly responsible for the illness fails to alleviate the symptoms. As above, treatment is initiated with the least toxic effective agents. If a patient fails to respond to simple antidiarrheal drugs, anti-inflammatory or immunosuppressive medications may be required. Studies of budesonide in LC have shown an 86% response rate in symptoms and in histologic findings, with an 81% response rate in CC. A treatment algorithm is discussed above.
Antidiarrheal agents
Class Summary
Appropriate in mild cases.
Loperamide (Imodium AD)
Poorly absorbable opiate that decreases colonic smooth muscle contraction and propulsive activity. Slows intestinal motility and delays colonic transit. Reduction of gastrointestinal secretion may contribute to the antidiarrheal effect. Well-tolerated and safe drug when taken in recommended dosages.
Diphenoxylate hydrochloride/atropine sulfate (Lomotil)
Antidiarrheal agent chemically related to narcotic analgesic meperidine. A subtherapeutic dose of anticholinergic atropine sulfate is added to discourage overdosage, in which case diphenoxylate may clinically mimic the effects of codeine.
Each tab of Lomotil (or 5 cc of elixir) contains 2.5 mg diphenoxylate hydrochloride and 0.025 mg atropine sulfate.
Bismuth subsalicylate (Pepto-Bismol)
Controls diarrhea by reducing fluid secretion into intestinal lumen, by binding bacterial toxins, or by acting as an antimicrobial agent.
Anion exchange resins
Class Summary
Diarrhea in patients with LC and possible bile salt malabsorption may respond to exchange resins.
Cholestyramine (Questran, LoCholest)
Absorbs bile salts in the intestine, resulting in an insoluble complex that is excreted in feces.
Antispasmodics
Class Summary
Some patients with cramping pain associated with diarrhea will respond to antispasmodic medication.
Hyoscyamine (Levsin SL, Levbid, Symax, Cystospaz)
Anticholinergic agent with limited and generally symptomatic utility in patients with colitis. Levsin or Levsin SL (sublingual) is dispensed as 0.125-mg tab, Cystospaz as 0.15-mg tab, and Levbid or Symax as 0.375-mg tabs.
Topical anti-inflammatory drugs
Class Summary
Drugs that reduce inflammatory changes at level of the colonic wall may be needed in subset of colitic patients who fail to respond to antidiarrheal medication.
Sulfasalazine (Azulfidine EN-tabs)
Prodrug complexing the active component of 5-aminosalicylic acid (5-ASA) with an inactive sulfapyridine moiety to prevent systemic absorption in upper gastrointestinal tract. In the colon, the diazo bond is cleaved by bacterial flora and active 5-ASA is released to function as a topical anti-inflammatory drug. Adverse effects typically are due to sulfapyridine rather than to 5-ASA.
Mesalamine (Asacol, Pentasa)
Controlled-released formulations of 5-ASA and cause fewer side effects than sulfasalazine due to absence of the sulfa moiety. Pentasa is ethylcellulose-coated 5-ASA coated with an acrylic-based resin that dissolves in neutral or alkaline pH found in the terminal ileum or the colon. Dissolution of the coating of these tablets releases active 5-ASA where it can be topically active. These medications are more costly than sulfasalazine but typically better tolerated. Asacol is dispensed in 400-mg tabs. Pentasa is available in 250-mg tab.
Corticosteroids
Class Summary
Systemic anti-inflammatory agents that are readily absorbed from the gastrointestinal tract. Have a multitude of significant side effects when used over a prolonged period of time. Patients who fail to respond adequately to topical anti-inflammatory drugs may benefit from a course of corticosteroid therapy.
Prednisone (Deltasone, Orasone, Sterapred)
Inexpensive corticosteroid available in many strengths, which simplifies tapering schedules. Methylprednisolone (Medrol), dexamethasone (Decadron), or hydrocortisone can be used instead of prednisone. Dosage should be adjusted based on relative potencies.
Budesonide (Entocort EC)
Topical glucocorticoid delivered to the small bowel and ascending colon in a time-dependent manner. Active drug is coated with methylcellulose which dissolves at pH of 5.5 or greater, starting in the duodenum. Does not suppress the hypothalamus-pituitary-adrenal axis to a significant degree.
Immunosuppressant drugs
Class Summary
Have been administered to small number of patients with LC who have not responded to other medical therapy. Specific indications and recommended dosages have not been established yet.
Azathioprine (Imuran), 6-mercaptopurine (Purinethol)
Azathioprine is an antimetabolite available in tablet form for oral administration or in 100-mg vials for IV injection and is an imidazolyl derivative of 6-mercaptopurine. It is cleaved in vivo to mercaptopurine. Both compounds are eliminated rapidly from blood and are oxidized or methylated in erythrocytes and liver. No azathioprine or mercaptopurine is detectable in urine 8 h after taken.
Methotrexate (Folex, Rheumatrex)
Previously known as amethopterin. Antimetabolite that inhibits dihydrofolic acid reductase. Also used in certain neoplastic diseases, severe psoriasis, and adult rheumatoid arthritis.
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