Treatment of Descending and Sigmoid Colitis

Introduction to Treatment

The American Gastroenterological Association recommends a combination of oral and topical mesalazine therapy as first-line treatment for descending and sigmoid colitis, with oral mesalazine 2-4g daily plus topical mesalazine 1g daily in the appropriate formulation for the extent of disease 1, 2, 3

For left-sided colitis, the European Crohn’s and Colitis Organisation suggests using oral mesalazine 2-4g daily or balsalazide 6.75g daily as effective first-line therapy 1, 2
Combining oral therapy with topical mesalazine is recommended for better efficacy than either alone, according to the American Gastroenterological Association 3, 4
Once-daily dosing with mesalazine is as effective as divided doses and may improve adherence, as stated by the American Gastroenterological Association 3
Olsalazine 1.5-3g daily is an alternative but has a higher incidence of diarrhea in extensive disease, according to the European Crohn’s and Colitis Organisation 2
Sulphasalazine 2-4g daily is effective but has more side effects than newer 5-ASA drugs; may be beneficial for patients with reactive arthropathy, as suggested by the European Crohn’s and Colitis Organisation 2

For sigmoid involvement, the American Gastroenterological Association recommends using mesalazine enemas rather than oral therapy alone 3
Topical mesalazine is more effective than topical corticosteroids, according to the American Gastroenterological Association 3
Topical corticosteroids should be reserved as second-line therapy for patients intolerant to topical mesalazine, as stated by the European Crohn’s and Colitis Organisation 1, 3
The choice of topical formulation should match disease extent: suppositories for rectosigmoid junction, foam or liquid enemas for more proximal disease, according to the European Crohn’s and Colitis Organisation 1, 5

If no improvement with combination of oral and topical mesalazine, the American Gastroenterological Association recommends initiating oral prednisolone 40mg daily 1, 5
Topical agents may be used as adjunctive therapy with systemic corticosteroids, as suggested by the European Crohn’s and Colitis Organisation 5, 6
Prednisolone should be tapered gradually over 8 weeks; more rapid reduction is associated with early relapse, according to the European Crohn’s and Colitis Organisation 5, 6
Long-term steroid treatment should be avoided due to significant side effects, as stated by the American Gastroenterological Association 4

For chronic active steroid-dependent disease, the European Crohn’s and Colitis Organisation recommends using azathioprine 1.5-2.5 mg/kg/day or mercaptopurine 0.75-1.5 mg/kg/day 1, 4
Cyclosporine may be effective for severe, steroid-refractory colitis, according to the European Crohn’s and Colitis Organisation 1

Disease activity should be confirmed by sigmoidoscopy and infection excluded before initiating treatment, as recommended by the American Gastroenterological Association 1, 2
Proximal constipation should be treated with stool bulking agents or laxatives, according to the American Gastroenterological Association 1, 4
Antidiarrheal medications should be avoided as they can mask worsening symptoms while allowing underlying inflammation to progress, as stated by the American Gastroenterological Association 4

Aminosalicylates are effective and safe for maintenance therapy, according to the American Gastroenterological Association 4

Ensure adequate dosing of mesalazine (at least 2g daily for active disease), as recommended by the European Crohn’s and Colitis Organisation 2
Delaying corticosteroid treatment if no response to optimized 5-ASA therapy should be avoided, according to the European Crohn’s and Colitis Organisation 6
Long-term steroid use should be avoided; transition to steroid-sparing agents if needed, as stated by the American Gastroenterological Association 4
The increased risk of adverse outcomes with severe disease in elderly patients should be considered, according to the American Gastroenterological Association 4