Medical Management of Microscopic Colitis

American Gastroenterological Association Institute Guideline on the Medical Management of Microscopic Colitis

Microscopic colitis presents as chronic watery diarrhea, is diagnosed by mucosal biopsy, and consists of the subtypes lymphocytic colitis and collagenous colitis. Management of the subtypes is similar. This new guideline from the AGA provides medical treatment recommendations and was published online November 13, 2015

Key Recommendations:
For symptomatic microscopic colitis, use budesonide as first-line therapy over mesalamine for induction of remission, and use budesonide for maintenance. During maintenance of remission, budesonide is typically tapered to the lowest effective dose. When budesonide therapy is not feasible, treat patients with mesalamine, bismuth salicylate, or prednisone for induction of remission. For induction of remission, do not treat patients with probiotics or Boswellia serrata, and do not add cholestyramine to mesalamine monotherapy.

 

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Recommendations:

• In patients with symptomatic microscopic colitis, the AGA recommends treatment with budesonide over no treatment for the induction of clinical remission.
• In patients with symptomatic microscopic colitis, the AGA recommends treatment with budesonide over mesalamine for the induction of clinical remission.
• In patients with symptomatic microscopic colitis in whom budesonide therapy is not feasible, the AGA suggests treatment with mesalamine over no treatment for the induction of clinical remission.
• In patients with symptomatic microscopic colitis in whom budesonide therapy is not feasible, the AGA suggests treatment with bismuth salicylate over no treatment for the induction of clinical remission.
• In patients with symptomatic microscopic colitis in whom budesonide therapy is not feasible, the AGA suggests treatment with prednisolone (or prednisone) over no treatment for the induction of clinical remission.
• In patients with symptomatic microscopic colitis, the AGA suggests against combination therapy with cholestyramine and mesalamine over mesalamine alone for the induction of clinical remission.
  • A single randomized clinical trial failed to show benefit from the addition of cholestyramine to mesalamine therapy. The AGA considered not only the uncertain balance between benefits and harms but also the feasibility of taking cholestyramine, which can interfere with the administration of other medications, especially in an older population in which polypharmacy is commonplace.
• In patients with symptomatic microscopic colitis, the AGA suggests against treatment with Boswellia serrata over no treatment for the induction of clinical remission.
• In patients with symptomatic microscopic colitis, the AGA suggests against treatment with probiotics over no treatment for the induction of clinical remission.
• For patients with recurrence of symptoms following discontinuation of induction therapy for microscopic colitis, the AGA recommends budesonide for maintenance of clinical remission.

Summary
The recommendations for the medical management of microscopic colitis are intended to reduce practice variation and promote high-value care. The evidence supports the first-line use of budesonide for induction and, when appropriate, maintenance therapy. 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. The effectiveness of lower-cost alternatives such as antidiarrheal agents (eg, loperamide) and cholestyramine monotherapy were not addressed and the role of combination therapies has yet to explored. Due to the absence of clinical trial data, this guideline did not address medical treatment of corticosteroid-refractory microscopic colitis. The guideline suggests that immunosuppressants such as azathioprine and anti–tumor necrosis factor agents may benefit these patients.

 

http://www.gastro.org

http://www.gastro.org/guidelines

http://www.gastrojournal.org/article/S0016-5085(15)01625-X/abstract

http://www.gastrojournal.org/article/S0016-5085(15)01625-X/fulltext