New Guideline Addresses Microscopic Colitis Management

Laurie Barclay, MD

December 18, 2015

A new American Gastroenterological Association Institute guideline on the medical management of microscopic colitis supports the first-line use of budesonide for induction and, when appropriate, maintenance therapy. The guideline appears in the January 2016 issue of Gastroenterology.

Microscopic colitis, which is characterized by chronic watery diarrhea caused by inflammation in the colon and diagnosed by colonic biopsy, affects predominantly those older than 60 years, with a prevalence ranging from 48 to 219 per 100,000, the guideline authors report. Although it is not associated with increased mortality, symptoms can reduce quality of life.

"Unlike other inflammatory colitides, there is no evidence that the persistence of histological inflammation portends long-term unfavorable outcomes such as colorectal cancer or need for surgery," Geoffrey C. Nguyen, MD, PhD, from the Mount Sinai Hospital Centre for Inflammatory Bowel Disease, University of Toronto, Ontario, Canada, and colleagues write. "Accordingly, the goal of medical therapy reflected in these recommendations is to relieve symptoms and improve quality of life while minimizing drug-related adverse effects."

Specific recommendations include:

  • For symptomatic patients, treatment with budesonide is preferable to no treatment, or to treatment with mesalamine, to induce clinical remission.

  • In symptomatic patients for whom budesonide therapy is not feasible, treatment with mesalamine, bismuth salicylate, or prednisolone (or prednisone) is preferable to no treatment to induce clinical remission.

  • In symptomatic patients, the American Gastroenterological Association suggests against combination therapy with cholestyramine and mesalamine, vs mesalamine alone, to induce clinical remission.

  • In symptomatic patients, the association suggests against treatment with Boswellia serrata or probiotics vs no treatment to induce clinical remission.

  • For patients with recurrent symptoms when induction therapy for microscopic colitis is discontinued, the association recommends budesonide to maintain clinical remission.

"Because the technical review and guideline focused on treatments assessed in clinical trials, it did not address the full armamentarium of therapies currently used in practice," Dr Nguyen and colleagues write. "We would endorse clinical trials that more rigorously assess the effectiveness of lower-cost alternatives such as antidiarrheal agents (eg, loperamide) and cholestyramine monotherapy with accompanying cost-effective analyses."

The authors have disclosed no relevant financial relationships.

Gastroenterology. 2016;150:242-246. Full text

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