Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Collagenous and Lymphocytic Colitis Medication

  • Author: Joyann A Kroser, MD, FACP, FACG, AGAF; Chief Editor: BS Anand, MD  more...
 
Updated: Nov 02, 2015
 

Medication Summary

Medication is indicated only if discontinuing dietary components or medications considered possibly responsible for the illness fail 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.

Next

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.

Previous
Next

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.

Previous
Next

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.

Previous
Next

Topical anti-inflammatory drugs

Class Summary

Drugs that reduce inflammatory changes at the level of the colonic wall may be needed in a subset of patients with colitis 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 the 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.

Previous
Next

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.

Previous
Next

Immunosuppressant drugs

Class Summary

Have been administered to a 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 administration.

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.

Previous
 
Contributor Information and Disclosures
Author

Joyann A Kroser, MD, FACP, FACG, AGAF Adjunct Clinical Associate Professor of Medicine, Gastroenterology, and Hepatology, Drexel University College of Medicine; Adjunct Professor of Medicine, Temple University School of Medicine

Joyann A Kroser, MD, FACP, FACG, AGAF is a member of the following medical societies: American College of Physicians, Alpha Omega Alpha, Crohn's and Colitis Foundation of America, American College of Gastroenterology, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, Pennsylvania Medical Society, Phi Beta Kappa, Philadelphia County Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Amandeep Singh, MBBS Resident Physician, Department of Internal Medicine, Crozer Chester Medical Center

Amandeep Singh, MBBS is a member of the following medical societies: American Academy of Family Physicians, American College of Gastroenterology, American College of Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Acknowledgements

Arun Chaudhary, MD Consulting Staff, Department of Internal Medicine, Wentworth-Douglass Hospital

Disclosure: Nothing to disclose.

Eric Goosenberg, MD Assistant Professor of Medicine, Temple University School of Medicine

Eric Goosenberg, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and Bockus International Society of Gastroenterology

Disclosure: Nothing to disclose.

Douglas M Heuman, MD, FACP, FACG, AGAF Chief of GI, Hepatology, and Nutrition at North Shore University Hospital/Long Island Jewish Medical Center; Professor, Department of Medicine, Hofstra North Shore-LIJ School of Medicine

Douglas M Heuman, MD, FACP, FACG, AGAF is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Physicians, and American Gastroenterological Association

Disclosure: Novartis Grant/research funds Other; Bayer Grant/research funds Other; Otsuka Grant/research funds None; Bristol Myers Squibb Grant/research funds Other; Scynexis None None; Salix Grant/research funds Other; MannKind Other

References
  1. Jauregui-Amezaga A, Vermeire S, Geboes K. Contemporary methods for the diagnosis and treatment of microscopic colitis. Expert Rev Gastroenterol Hepatol. 2015 Oct 15. 1-15. [Medline].

  2. Freeman HJ, Weinstein WM, Shnitka TK, et al. Watery diarrhea syndrome associated with a lesion of the colonic basement membrane (CD)-lamina propria (LP) interface. Ann R Coll Phys Surg Can. 1976. 9:45.

  3. Mahajan D, Goldblum JR, Xiao SY, Shen B, Liu X. Lymphocytic colitis and collagenous colitis: a review of clinicopathologic features and immunologic abnormalities. Adv Anat Pathol. 2012 Jan. 19(1):28-38. [Medline].

  4. Bjornbak C, Engel PJ, Nielsen PL, Munck LK. Microscopic colitis: clinical findings, topography and persistence of histopathological subgroups. Aliment Pharmacol Ther. 2011 Nov. 34(10):1225-34. [Medline].

  5. Villanueva MS, Alimi Y. Microscopic colitis (lymphocytic and collagenous), eosinophilic colitis, and celiac disease. Clin Colon Rectal Surg. 2015 Jun. 28 (2):118-26. [Medline].

  6. Yen EF, Pokhrel B, Du H, Nwe S, Bianchi L, Witt B, et al. Current and past cigarette smoking significantly increase risk for microscopic colitis. Inflamm Bowel Dis. 2011 Dec 6. [Medline].

  7. Kandemir O, Utas C, Gonen O, et al. Colonic subepithelial collagenous thickening in diabetic patients. Dis Colon Rectum. 1995 Oct. 38(10):1097-100. [Medline].

  8. Christ AD, Meier R, Bauerfeind P, Wegmann W, Gyr K. [Simultaneous occurrence of lymphocytic gastritis and lymphocytic colitis with transition to collagenous colitis] [German]. Schweiz Med Wochenschr. 1993 Jul 31. 123(30):1487-90. [Medline].

  9. O'Mahony S, Nawroz IM, Ferguson A. Coeliac disease and collagenous colitis. Postgrad Med J. 1990 Mar. 66(773):238-41. [Medline]. [Full Text].

  10. Freeman HJ. Collagenous colitis as the presenting feature of biopsy-defined celiac disease. J Clin Gastroenterol. 2004 Sep. 38(8):664-8. [Medline].

  11. Kingsmore SF, Kingsmore DB, Hall BD, Wilson JA, Gottfried MR, Allen NB. Cooccurrence of collagenous colitis with seronegative spondyloarthropathy: report of a case and literature review. J Rheumatol. 1993 Dec. 20(12):2153-7. [Medline].

  12. Lettesjo H, Hansson T, Peterson C, et al. Detection of inflammatory markers in stools from patients with irritable bowel syndrome and collagenous colitis. Scand J Gastroenterol. 2006 Jan. 41(1):54-9. [Medline].

  13. Gunaltay S, Kumawat AK, Nyhlin N, et al. Enhanced levels of chemokines and their receptors in the colon of microscopic colitis patients indicate mixed immune cell recruitment. Mediators Inflamm. 2015. 2015:132458. [Medline].

  14. Miehlke S, Madisch A, Karimi D, et al. Budesonide is effective in treating lymphocytic colitis: a randomized double-blind placebo-controlled study. Gastroenterology. 2009 Jun. 136(7):2092-100. [Medline].

  15. Baert F, Wouters K, D'Haens G, Hoang P, Naegels S, D'Heygere F, et al. Lymphocytic colitis: a distinct clinical entity? A clinicopathological confrontation of lymphocytic and collagenous colitis. Gut. 1999 Sep. 45(3):375-81. [Medline].

  16. Baum CA, Bhatia P, Miner PB Jr. Increased colonic mucosal mast cells associated with severe watery diarrhea and microscopic colitis. Dig Dis Sci. 1989 Sep. 34(9):1462-5. [Medline].

  17. Bo-Linn GW, Vendrell DD, Lee E, Fordtran JS. An evaluation of the significance of microscopic colitis in patients with chronic diarrhea. J Clin Invest. 1985 May. 75(5):1559-69. [Medline].

  18. Burgel N, Bojarski C, Mankertz J, Zeitz M, Fromm M, Schulzke JD. Mechanisms of diarrhea in collagenous colitis. Gastroenterology. 2002 Aug. 123(2):433-43. [Medline].

  19. Cappell MS. Colonic toxicity of administered drugs and chemicals. Am J Gastroenterol. May 2004. 99(6):1175-90. [Medline].

  20. Chande N, MacDonald JK, McDonald JW. Interventions for treating microscopic colitis: a Cochrane Inflammatory Bowel Disease and Functional Bowel Disorders Review Group systematic review of randomized trials. Am J Gastroenterol. 2009 Jan. 104(1):235-41; quiz 234, 242. [Medline].

  21. Chande N, McDonald JW, Macdonald JK. Interventions for treating collagenous colitis: a Cochrane Inflammatory Bowel Disease Group systematic review of randomized trials. Am J Gastroenterol. 2004 Dec. 99(12):2459-65. [Medline].

  22. Fernandez-Banares F, Esteve M, Espinos JC, Rosinach M, Forne M, Salas A, et al. Drug consumption and the risk of microscopic colitis. Am J Gastroenterol. 2007 Feb. 102(2):324-30. [Medline].

  23. Fernandez-Banares F, Salas A, Esteve M, Espinos J, Forne M, Viver JM. Collagenous and lymphocytic colitis. evaluation of clinical and histological features, response to treatment, and long-term follow-up. Am J Gastroenterol. 2003 Feb. 98(2):340-7. [Medline].

  24. Fernandez-Banares F, Salas A, Forne M, Esteve M, Espinos J, Viver JM. Incidence of collagenous and lymphocytic colitis: a 5-year population-based study. Am J Gastroenterol. 1999 Feb. 94(2):418-23. [Medline].

  25. Freeman HJ. Collagenous mucosal inflammatory diseases of the gastrointestinal tract. Gastroenterology. 2005 Jul. 129(1):338-50. [Medline].

  26. Giardiello FM, Lazenby AJ. The atypical colitides. Gastroenterol Clin North Am. 1999 Jun. 28(2):479-90, x. [Medline].

  27. Giardiello FM, Lazenby AJ, Bayless TM. The new colitides, Collagenous, lymphocytic, and diversion colitis. Gastroenterol Clin North Am. 1995 Sep. 24(3):717-29. [Medline].

  28. Giardiello FM, Lazenby AJ, Yardley JH, Bias WB, Johnson J, Alianiello RG, et al. Increased HLA A1 and diminished HLA A3 in lymphocytic colitis compared to controls and patients with collagenous colitis. Dig Dis Sci. 1992 Apr. 37(4):496-9. [Medline].

  29. Limsui D, Pardi DS, Camilleri M, Loftus EV Jr, Kammer PP, Tremaine WJ, et al. Symptomatic overlap between irritable bowel syndrome and microscopic colitis. Inflamm Bowel Dis. 2007 Feb. 13(2):175-81. [Medline].

  30. Marshall JB, Singh R, Diaz-Arias AA. Chronic, unexplained diarrhea: are biopsies necessary if colonoscopy is normal?. Am J Gastroenterol. 1995 Mar. 90(3):372-6. [Medline].

  31. Maxson CJ, Klein HD, Rubin W. Atypical forms of inflammatory bowel disease. Med Clin North Am. 1994 Nov. 78(6):1259-73. [Medline].

  32. Miehlke S, Madisch A, Bethke B, Morgner A, Kuhlisch E, Henker C, et al. Oral budesonide for maintenance treatment of collagenous colitis: a randomized, double-blind, placebo-controlled trial. Gastroenterology. 2008 Nov. 135(5):1510-6. [Medline].

  33. Miehlke S, Madisch A, Karimi D, Wonschik S, Kuhlisch E, Beckmann R. Budesonide is effective in treating lymphocytic colitis: a randomized double-blind placebo-controlled study. Gastroenterology. 2009 Jun. 136(7):2092-2100. [Medline].

  34. Mosnier JF, Larvol L, Barge J, Dubois S, De La Bigne G, Henin D, et al. Lymphocytic and collagenous colitis: an immunohistochemical study. Am J Gastroenterol. 1996 Apr. 91(4):709-13. [Medline].

  35. Mullhaupt B, Guller U, Anabitarte M, Guller R, Fried M. Lymphocytic colitis: clinical presentation and long term course. Gut. 1998 Nov. 43(5):629-33. [Medline].

  36. Pardi DS. After budesonide, what next for collagenous colitis?. Gut. 2009 Jan. 58(1):3-4. [Medline].

  37. Pardi DS. Microscopic colitis. Gastroenterol & Hepatol. April 2009. 5(4):283-288.

  38. Pardi DS. Microscopic colitis. Mayo Clin Proc. 2003 May. 78(5):614-6; quiz 616-7. [Medline].

  39. Pardi DS, Loftus EV Jr, Smyrk TC, Kammer PP, Tremaine WJ, Schleck CD, et al. The epidemiology of microscopic colitis: a population based study in Olmsted County, Minnesota. Gut. 2007 Apr. 56(4):504-8. [Medline].

  40. Pardi DS, Ramnath VR, Loftus EV Jr, Tremaine WJ, Sandborn WJ. Lymphocytic colitis: clinical features, treatment, and outcomes. Am J Gastroenterol. 2002 Nov. 97(11):2829-33. [Medline].

  41. Schiller LR. Chronic diarrhea. Gastroenterology. 2004 Jul. 127(1):287-93. [Medline].

  42. Shah V, Lyford G, Gores G, Farrugia G. Nitric oxide in gastrointestinal health and disease. Gastroenterology. 2004 Mar. 126(3):903-13. [Medline].

  43. Taha Y, Raab Y, Larsson A, Carlson M, Loof L, Gerdin B, et al. Vascular endothelial growth factor (VEGF)--a possible mediator of inflammation and mucosal permeability in patients with collagenous colitis. Dig Dis Sci. 2004 Jan. 49(1):109-15. [Medline].

  44. Zins BJ, Sandborn WJ, Tremaine WJ. Collagenous and lymphocytic colitis: subject review and therapeutic alternatives. Am J Gastroenterol. 1995 Sep. 90(9):1394-400. [Medline].

  45. Colussi D, Salari B, Stewart KO, et al. Clinical characteristics and patterns and predictors of response to therapy in collagenous and lymphocytic colitis. Scand J Gastroenterol. 2015. 50 (11):1382-8. [Medline].

 
Previous
Next
 
Lymphocytic colitis (LC) showing marked chronic inflammatory cell infiltrate of the surface epithelium (on right) with preservation of crypt architecture. Subepithelial collagen layer is not thickened.
Collagenous colitis (CC) showing similar inflammatory cell infiltration as in lymphocytic colitis (LC), with the characteristically thickened subepithelial collagen layer.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.