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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.


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.



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 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.



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 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.

Contributor Information and Disclosures

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.


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.


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

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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.
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