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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.
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/guidelines
http://www.gastrojournal.org/article/S0016-5085(15)01625-X/abstract
http://www.gastrojournal.org/article/S0016-5085(15)01625-X/fulltext
Clostridium Difficile Infections
The American College of Gastroenterology published updated guidelines on Clostridium Difficile infection.
Clostridium difficile infection (CDI) is a leading cause of hospital-associated illness and is becoming a more difficult infection to control and treat. Fecal stool transfer is now being discussed and patients are becoming more aware of the difficult issues related to this intestinal infection. The current guidelines are therefore posted to provide our readers with a basis for further discussions with their physicians. It is suggested that patients are treated depending on severity of disease (mild-to-moderate, severe, or complicated disease). Therapy with metronidazole remains the choice for mild to moderate disease but may not be adequate for patients with severe or complicated disease.
Diagnostic tests
- Only stools from patients with diarrhea should be tested for Clostridium difficile.
- Repeat testing should be discouraged.
- Testing for cure should not be done.
Management of mild, moderate, and severe CDI
- If a patient has strong a pre-test suspicion for CDI, empiric therapy for CDI should be considered regardless of the laboratory testing result.
- Any inciting antibiotics should be discontinued, if possible.
- Patients with mild-to-moderate CDI should be treated with metronidazole 500 mg orally three times per day for 10 days.
- Patients with severe CDI should be treated with vancomycin 125 mg four times daily for 10 days.
- Failure to respond to metronidazole therapy within 5 – 7 days should prompt consideration of a change in therapy to vancomycin at standard dosing.
- For mild-to-moderate CDI in patients who are intolerant / allergic to metronidazole and for pregnant / breastfeeding women, vancomycin should be used at standard dosing.
- In patients in whom oral antibiotics cannot reach a segment of the colon, such as with Hartman’s pouch, ileostomy, or colon diversion, vancomycin therapy delivered via enema should be added to treatments above until the patient improves.
- The use of anti-peristaltic agents to control diarrhea should be avoided, as they may obscure symptoms and precipitate complicated disease. If used, anti-peristaltic agents must be accompanied by medical therapy for CDI.
- For complicated disease, supportive care should be offered i.e. iv fluids and electrolyte replacement. In the absence of ileus or significant abdominal distention, oral or enteral feeding should be continued.
- CT scanning of the abdomen and pelvis is recommended in complicated CDI.
- Oral vancomycin (125 mg four times per day) plus iv metronidazole (500 mg three times a day) is the treatment of choice in severe and complicated CDI.
- Vancomycin delivered orally (500 mg four times per day) and per rectum (500 mg in a volume of 500 ml four times a day) plus intravenous metronidazole (500 mg three times a day) is the treatment of choice for patients with complicated CDI with ileus or toxic colon and / or significant abdominal distention.
- Surgical consultation should be obtained in all patients with complicated disease and considered in patients with any one of the following:
- hypotension requiring vasopressor therapy
- clinical signs of sepsis and organ dysfunction (renal and pulmonary)
- mental status changes
- white blood cell count ≥ 50,000 cells / μ l, lactate ≥ 5 mmol / l
- failure to improve on medical therapy after 5 days.
Management of recurrent CDI (RCDI)
Patient face a 30% recurrence risk with the first infection and a 60% recurrence risk if a second infection has occurred.
- The first recurrence of CDI can be treated with the same regimen as used for the initial episode. If severe, however vancomycin should be used.
- The second recurrence should be treated with a pulsed vancomycin regimen.
- If there is a third recurrence after a pulsed vancomycin regimen, fecal microbiota transplant (FMT) should be considered.
- There is limited evidence for the use of adjunct probiotics to decrease recurrences in patients with RCDI.
- No effective immunotherapy is currently available.
Management of patients with CDI and co-morbid conditions
- All IBD patients hospitalized with a disease flare should undergo testing for CDI.
- IBD patients with diarrhea in the setting of prior quiescent disease, or in the presence of risk factors (i.e. recent hospitalization, antibiotic use) should be tested.
- Patients with IBD and severe colitis may benefit from empiric therapy against CDI and treatment of an IBD flare while awaiting results of C. difficile testing.
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