Approach Considerations
United European Gastroenterology (UEG) and the European Microscopic Colitis Group (EMCG) recommend the following for treatment of microscopic colitis (MC) [10] :
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For induction of remission in collagenous colitis (CC) or lymphocytic colitis (LC): Oral budesonide
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Oral budesonide is effective for maintaining remission in patients with collagenous colitis; it is suggested for maintaining remission in patients with lymphocytic colitis
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Budesonide in microscopic colitis is not associated with an increased risk of serious adverse events
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The risk of osteoporotic bone fractures does not appear to be increased in patients with microscopic colitis who are treated with budesonide; however, there may be an associated reduction in bone mineral density with prolonged use
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Mesalazine therapy is not recommended for induction of remission in patients with microscopic colitis. No studies exist for maintenance
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Not enough evidence exists for recommending bismuth subsalicylate, loperamide, nor antibiotics in cases of microscopic colitis. However, given loperamide’s documented effects in chronic diarrhea, loperamide is favored in mild microscopic colitis disease
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For microscopic colitis and bile acid diarrhea, bile acid binders are suggested for treatment
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Probiotics, prednisolone or other corticosteroids than budesonide, as well as methotrexate are not recommended as treatment of microscopic colitis
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Recommended treatment includes thiopurines, anti-tumor necrosis factor (anti-TNF) drugs, or vedolizumab in patients with budesonide-refractory microscopic colitis to induce and maintain clinical remission
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Consider surgery as the last option in selected patients with microscopic colitis if all medical therapy fails
Medical Care
Medical treatment
Medical treatment is not different for different subtypes of microscopic colitis (MC). Similar responses to treatment have been reported throughout the literature. The following treatment guidelines are based on the American Gastroenterological Association (AGA) Institute guidelines. [38, 39]
Patients are also advised to avoid any offending medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), proton pump inhibitors (PPIs), and selective serotonin reuptake inhibitors (SSRIs) if a chronological relationship is established or if symptoms persist in spite of treatment
Antidiarrheal agents such as loperamide may be used in mild cases (< 3 stools per day) or in conjunction with other therapies for symptomatic relief.
The treatment algorithm is as follows [38, 39] :
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First line: Budesonide 9 mg daily for at least 8 weeks. Once symptom remission has been achieved, patients can be gradually tapered off budesonide. If no recurrence of symptoms occurs, no maintenance therapy is needed. If patients develop recurrent symptoms after stopping budesonide, they can go on maintenance therapy with the lowest effective dose of budesonide: 3-6 mg daily for 6-12 months.
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Second line: If the patient unable to tolerate budesonide or if it is not feasible, second-line treatment is with mesalamine or bismuth salicylate or oral prednisone or prednisolone.
Alternative therapies like cholestyramine can be used in mild cases of microscopic colitis. However, the use of cholestyramine along with mesalamine is not recommended due to decreased absorption of mesalamine.
Multiple other agents such as Boswellia serrata, probiotics, and octreotide have been studied but did not show consistent results. Some small studies have shown efficacy with anti-tumor necrosis factor (TNF) therapy or immunomodulators like methotrexate or azathioprine in refractory cases. [40, 41, 42]
In rare scenarios, where patients continue to have significant diarrhea in spite of medical therapy, colectomy might be considered.
Diet and activity
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.
Consultations
Consultation with a gastroenterologist is often needed to make the diagnosis and to work through the treatment algorithm.
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Microscopic Colitis (Collagenous and Lymphocytic Colitis). Lymphocytic colitis (LC) showing marked chronic inflammatory cell infiltrate of the surface epithelium (on right) with preservation of the crypt architecture. The subepithelial collagen layer is not thickened.
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Microscopic Colitis (Collagenous and Lymphocytic Colitis). Collagenous colitis (CC) showing similar inflammatory cell infiltration as in lymphocytic colitis (LC), with the characteristically thickened subepithelial collagen layer.
