Management of Ulcerative Proctitis

First‑Line Therapy

Topical mesalamine suppositories are recommended as the initial treatment for mild‑to‑moderate ulcerative proctitis; they achieve higher induction remission rates (relative risk ≈ 2.7) and better maintenance of remission (relative risk ≈ 2.1) than oral mesalamine, representing the strongest evidence‑based option for this localized disease. 1

Adding oral mesalamine (2–3 g/day) to ongoing topical therapy provides superior efficacy compared with either modality alone in patients who fail to respond within 2–4 weeks. 2
If mesalamine is intolerable, substituting a rectal corticosteroid (foam or suppository) is acceptable, although long‑term disease control is inferior to that achieved with mesalamine. 1

Topical tacrolimus (0.5–1 mg twice daily as suppository or enema) has demonstrated efficacy in patients who have failed both topical and oral 5‑ASA plus corticosteroids and should be considered before moving to systemic advanced therapies. 2
Short‑course oral prednisolone can be used for induction in refractory cases but must not be continued for maintenance therapy. 2
For truly refractory disease, escalation to advanced agents—including Janus kinase inhibitors, sphingosine‑1‑phosphate (S1P) modulators, or biologic anti‑TNF agents—is appropriate. 2

Relying solely on oral mesalamine for isolated proctitis is ineffective; topical therapy must remain the first‑line approach. 1
Repeated courses of corticosteroids should be avoided; if a patient requires more than one course, therapy should be escalated to an advanced agent rather than continuing steroid cycling. 2

Clinical response should be evaluated within 2–4 weeks of therapy initiation; lack of improvement warrants immediate escalation. 2
Endoscopic assessment at 3–6 months after starting treatment is recommended to verify mucosal healing, which is the preferred therapeutic target over symptom resolution alone. 2

When rectal therapy is absolutely refused or not tolerated, high‑dose oral mesalamine (>3 g/day) may be used as an alternative, acknowledging its lower efficacy compared with topical formulations. 1