eMedicine Specialties > Gastroenterology > Colon
Collagenous and Lymphocytic Colitis: Treatment & Medication
Updated: Jul 15, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Evaluating treatment options is impaired by the fairly frequent occurrence of spontaneous remission of symptoms; however positive placebo-controlled double-blind randomized trials of budesonide have been performed and reported in both LC and CC.
- A trial of dietary restriction and avoidance of potentially aggravating drugs (particularly nonsteroidal anti-inflammatory drugs) may alleviate symptoms in some patients, but many will require medical therapy.
- Treatment should be initiated with the least toxic regimen or medication, with stronger medication used only if milder treatment fails. Generally, 4-6 weeks should be allowed before deeming a particular medication ineffective in the treatment of CC or LC.
- One possible treatment algorithm is as follows:
- First line: Loperamide (Imodium AD) or diphoxylate/atropine (Lomotil) for mild diarrhea.
- Second line: Bismuth subsalicylate, two or three 262 mg tab tid or qid for 1-2 months (effective in up to 90% of patients); mesalamine, 3 g/d for 8 wk; or cholestyramine (especially if bile acid malabsorption is documented), at a mean dose of 8 g/d in moderate disease.
- Third line: If patient is still not responding or if a patient has clinically more severe colitis, a 6-week course of budesonide at the lowest effective dosage (usually 9 mg each morning) or a 2-week course of high-dose prednisone (60-80 mg/d) before tapering can be prescribed. Longer courses of budesonide may be beneficial, and, while systemic adverse effects may occur, little or no adrenal suppression should be anticipated. Recurrences after discontinuation of budesonide usually respond to reinstitution of this same medication. Longer courses of prednisone (up to 2 mo before tapering) may be needed in some patients, but recurrence is common after its discontinuation. In a randomized, double-blind, placebo-controlled study, Miehlke et al evaluated treatment of lymphocytic colitis with oral budesonide.2 At week 6, remission was documented by colonoscopy and histology in 86% of the budesonide group compared with 48% of those administered placebo (P = 0.01). Histologic remission was confirmed in 73% of those receiving budesonide and 31% of patients administered placebo (P = 0.03).2 Relapse during follow-up was evident in about 44% (15 patients), but 8 of those who had a relapse again had a response to budesonide. Clinical remission and improved histology is achieved in a majority of patients with lymphocytic colitis when treated with budesonide.2
- Fourth line: Some refractory cases may benefit from azathioprine (approximately 2 g/kg/d) or 6-mercaptopurine, but responses often take months to occur. Methotrexate can alternatively be used in this setting.
- Patients who respond to treatment, but experience a recurrence, will often respond again to the same previously effective medication.
Surgical Care
If colitis is refractory to continued medical therapy or if effective medication cannot be tolerated, colectomy or ileostomy might be the only effective therapy; however, this seldom is necessary.
Consultations
Consultation with a gastroenterologist often is needed to make the diagnosis and to work through the treatment algorithm.
Diet
- Patients should avoid or eliminate possible secretagogues, such as caffeine, and, when appropriate, lactose-containing products.
- A low-fat diet is advisable if steatorrhea is documented.
Medication
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
Appropriate in mild cases.
Loperamide hydrochloride (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.
Adult
Chronic diarrhea conditions: 2 mg (1 cap or 10 cc elixir) PO after each loose bowel movement; not to exceed 16 mg/d
Pediatric
<2 years: Not established
2-5 years: 1 tsp PO after first loose bowel movement, followed by 1 tsp after each subsequent loose bowel movement; not to exceed 3 tsp/d
6-8 years: 2 tsp or 1 cap after first loose bowel movement, followed by 1 tsp or one half cap PO after each subsequent loose bowel movement; not to exceed 4 tsp or 2 cap per d
9-12 years: 2 tsp or 1 cap PO after first loose bowel movement, followed by 1 tsp or one half cap PO after each subsequent loose bowel movement; not to exceed 6 tsp or 3 cap per d
>12 years: Administer as in adults
Phenothiazines, tricyclic antidepressants, and CNS depressants may increase loperamide toxicity
Documented hypersensitivity; high fever (temperature >101°C); blood or mucus in stools
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Concurrent antibiotic therapy; pregnancy; in case of accidental overdose, seek professional assistance or contact poison control center immediately; discontinue use if no clinical improvement in 48 h; because loperamide primarily is metabolized in liver, monitor for CNS toxicity in patients with hepatic insufficiency; do not use medication if high fever or blood in stool coincides with diarrhea
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.
Adult
2 cap (or 10 cc elixir) PO qid until symptoms are under control; then use smallest effective dose
Pediatric
<2 years: Not recommended
<12 years: Use liquid Lomotil; do not use tab
Initial: 0.3-0.4 mg/kg PO qd divided qid; adjust dose downward according to overall nutritional status and degree of dehydration
>12 years: Administer as in adults
Lomotil may delay metabolism of drugs in liver; CNS depressants, MAOIs, and antimuscarinic agents may increase the toxicity of this drug combination
Documented hypersensitivity; diarrhea caused by C difficile or other enterotoxin-producing bacterial pathogens; obstructive jaundice
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Overdosage may result in severe respiratory depression; carefully monitor and maintain fluid and electrolyte levels; because a subtherapeutic dose of atropine has been added to diphenoxylate hydrochloride, consider precautions relating to atropine; caution patient regarding activities requiring mental alertness, such as driving or operating dangerous machinery; explain potential reactions with concurrent administration of alcohol, barbiturates, or other tranquilizers
Bismuth subsalicylate (Pepto-Bismol)
Controls diarrhea by reducing fluid secretion into intestinal lumen, by binding bacterial toxins, or by acting as an antimicrobial agent.
Adult
3 tab PO in morning, 2 tab PO at noon, and 3 tab PO at night for an 8-wk trial
Pediatric
<3 years: Use special caution
3-6 years: One-third tab PO, repeat q0.5-1h prn; not to exceed 8 doses/24 h
6-9 years: Two-thirds tab PO, repeat q0.5-1h prn; not to exceed 8 doses/24 h
9-12 years: 1 tab PO, repeat q0.5-1h prn; not to exceed 8 doses/24 h
>12 years: Administer as in adults
Coadministration with anticoagulants may increase risk of bleeding; may increase toxicity of aspirin and hypoglycemics; decreases effects of tetracyclines and uricosurics
Documented hypersensitivity; children with chickenpox and flu; diarrhea with high fever, mucus, or blood is possible contraindication
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
May cause temporary and harmless darkening of tongue and/or black stool; alcohol consumption may cause abdominal cramps, nausea, and vomiting; drink plenty of clear fluids to help prevent dehydration
Anion exchange resins
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.
Adult
9 g of Questran (1 packet or 1 level scoopful contains 4 g of anhydrous cholestyramine resin) PO qd or bid with fluids initially; not to exceed 6 packets or scoopfuls in a d
Pediatric
Not established
Cholestyramine adsorbs many medications; other drugs should be taken at least 1 h before or 6 h after cholestyramine is ingested; because of bile salt adsorption, systemic absorption of dietary fat and fat-soluble vitamins (A, D, E, and K) may be impaired
Documented hypersensitivity; complete biliary obstruction
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in renal insufficiency or volume depletion; prolonged use may result in vitamin K and folic acid deficiency or hyperchloremic acidosis
Antispasmodics
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.
Adult
Levsin or Cystospaz: 1-2 tab PO (or SL if using Levsin SL) q4h; not to exceed 12 tab per 24 h
Levbid or Symax: 1 tab q12h
Pediatric
<12 years: Reduce dosage in proportion to age and weight
>12 years: Administer as in adults
Cholinergic blockade may occur when used with other antimuscarinics, amantadine, haloperidol, phenothiazine, MAOIs, tricyclic antidepressants, or some antihistamines; antacids may interfere with absorption
Documented hypersensitivity; glaucoma; obstructive uropathy; small or large bowel obstruction; pyloric stenosis; achalasia; paralytic ileus; severe ulcerative colitis; toxic megacolon; myasthenia gravis
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in coronary heart disease; congestive heart failure; arrhythmias; autonomic neuropathy; hyperthyroidism; hypertension; reflux esophagitis
Topical anti-inflammatory drugs
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.
Adult
Initially: 500-1000 mg PO bid/qid, with ideal dose being lowest effective dose
Dosage reduction may be required with concurrent oral anticoagulants, sulfonylurea hypoglycemic agents, and hydantoin anticonvulsants
Pediatric
<2 years: Not established
>2 years:
Initial: 40-60 mg/kg PO qd in 3-6 divided doses
Maintenance: 30 mg/kg PO qd divided qid
Possible dosage reduction required with concurrent oral anticoagulants, sulfonylurea hypoglycemic agents, and hydantoin anticonvulsants
Effects of oral anticoagulants, sulfonylurea hypoglycemic agents, and hydantoin anticonvulsants can be potentiated by sulfonamides (may need to adjust dose of these medications to avoid toxicity)
Documented hypersensitivity; urinary obstruction
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Do not crush or chew tab; swallow with plenty of water; avoid excessive exposure to sunlight; caution in patients with renal or hepatic impairment and blood dyscrasias
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.
Adult
Asacol: 400-1200 mg PO tid
Pentasa: 1000 mg PO qid
Pediatric
Not established
Decreases effect of iron, digoxin, and folic acid; mesalamine increases effect of oral anticoagulants, methotrexate, and oral hypoglycemic agents
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Impaired hepatic and renal function; can cause acute tolerance syndrome, which may be difficult to distinguish from inflammatory bowel disease; elderly people may have difficulty administering and retaining rectal suppositories; caution in patients with renal or hepatic impairment
Corticosteroids
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.
Adult
30-40 mg PO qd for 2 wk to 2 mo, then taper as tolerated
Pediatric
4-5 mg/m2/d PO; alternatively, 0.05-2 mg/kg PO divided bid/qid; taper over 2 wk, as symptoms resolve
Barbiturates, hydantoin, and rifampin increase metabolism of corticosteroids by induction of hepatic microsomal enzymes; macrolides, oral contraceptive pills, and ketoconazole can potentiate corticosteroid effects; can worsen symptoms of myasthenia gravis; increased risk of gastric ulcerations with concurrent NSAID or aspirin use
Documented hypersensitivity; viral infection; peptic ulcer disease; hepatic dysfunction; connective tissue infections; fungal or tubercular skin infections
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use; abrupt discontinuation of glucocorticoids may cause adrenal crisis (adrenal insufficiency)
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.
Adult
9 mg PO qd for up to 8 wk
Pediatric
Not established
Ketoconazole, itraconazole, ritonavir, indinavir, saquinavir, erythromycin, and other CYP3A4 enzyme inhibitors may significantly increase serum levels of budesonide
Documented hypersensitivity; systemic fungal infections; ileocolostomy during immediate or early postoperative period
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
If improvement fails to occur within 2-3 wk, discontinue therapy; symptomatic improvement may be misleading and should not be used as sole criterion in judging efficacy (sigmoidoscopic examination and x-ray visualization are essential for adequate monitoring); caution where there is a probability of impending perforation or abscess, pyogenic infections, intestinal anastomoses, obstruction, extensive fistulas and sinus tracts; caution in patients with tuberculosis or other infections, hypertension, diabetes mellitus, osteoporosis, peptic ulcer disease, glaucoma or cataracts
Immunosuppressant drugs
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.
Adult
Not established; 1 mg/kg/d PO for 6-8 wk suggested, increase by 0.5 mg/kg PO q4wk until response or dose reaches 2.5 mg/kg/d
Need to decrease dose if concurrently taking allopurinol
Pediatric
Initial dose: 2-5 mg/kg/d PO/IV
Maintenance dose: 1-2 mg/kg/d PO/IV
Toxicity increases with allopurinol; concurrent use with ACE inhibitors may induce severe leukopenia; may increase levels of methotrexate metabolites and decrease effects of anticoagulants, neuromuscular blockers, and cyclosporine
Documented hypersensitivity; previous treatment with alkylating agents such as cyclophosphamide, chlorambucil, and melphalan due to prohibitive risk of inducing malignancy; pregnancy is a relative contraindication
Pregnancy
D - Unsafe in pregnancy
Precautions
A severe gastrointestinal hypersensitivity reaction may occur during first several weeks of use; symptoms are reversible upon discontinuation of therapy; rechallenge with single dose can cause recurrence of symptoms within a few hours
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.
Adult
Not established; suggested dose is 7.5 mg PO qwk or 2.5 mg PO q12h for 3 doses/wk; not to exceed 20 mg/wk
Use relatively low doses in elderly people; closely monitor for early signs of toxicity
Pediatric
Not established
Oral aminoglycosides may decrease absorption and blood levels of concurrent oral methotrexate (MTX); charcoal lowers MTX levels; coadministration with etretinate may increase hepatotoxicity of MTX; folic acid or its derivatives contained in some vitamins may decrease response to MTX; indomethacin and phenylbutazone can increase MTX plasma levels; may decrease phenytoin serum levels; severe gastrointestinal toxicity and bone marrow suppression has occurred in some patients who have concurrently taken high-dose MTX with some NSAIDs; probenecid, salicylates, procarbazine, and sulfonamides, including TMP-SMZ, may increase effects and toxicity of MTX; may increase plasma levels of thiopurines
Documented hypersensitivity; alcoholism; hepatic insufficiency; documented immunodeficiency syndromes; preexisting blood dyscrasias (eg, bone marrow hypoplasia, leukopenia, thrombocytopenia, significant anemia); pregnancy
Pregnancy
X - Contraindicated in pregnancy
Precautions
Monitor CBCs monthly and liver and renal function q1-3mo during therapy; monitor more frequently during initial dosing, dose adjustments, or when risk of elevated MTX levels, eg, dehydration; MTX has toxic effects on hematologic, renal, GI, pulmonary, and neurologic systems; discontinue if significant drop in blood counts occurs; aspirin, NSAIDs, or low-dose steroids may be administered concomitantly with MTX (possibility of increased toxicity with NSAIDs, including salicylates, has not been tested)
More on Collagenous and Lymphocytic Colitis |
| Overview: Collagenous and Lymphocytic Colitis |
| Differential Diagnoses & Workup: Collagenous and Lymphocytic Colitis |
 Treatment & Medication: Collagenous and Lymphocytic Colitis |
| Follow-up: Collagenous and Lymphocytic Colitis |
| Multimedia: Collagenous and Lymphocytic Colitis |
| References |
| « Previous Page | Next Page » |
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Further Reading
Keywords
collagenous colitis, CC, lymphocytic colitis, LC, microscopic colitis
