New guideline recommends budesonide for treating microscopic colitis

Last Updated: 2015-12-18

By Will Boggs MD

NEW YORK (Reuters Health) - Budesonide should be the primary treatment for microscopic colitis, according to new guidelines from the American Gastroenterological Association (AGA) Institute.

"Budesonide is a mainstay of medical treatment for microscopic colitis," lead author Dr. Geoffrey C. Nguyen from the University of Toronto in Canada told Reuters Health by email. "It is the only current treatment that is supported by moderate-high quality of evidence from clinical trials."

Microscopic colitis, a chronic watery diarrhea caused by inflammation in the colon, affects between 48 and 219 per 100,000 persons. Although its symptoms can impair quality of life, its persistence does not appear to increase mortality or such long-term unfavorable outcomes as colorectal cancer or the need for surgery. So the goal of medical therapy is to relieve symptoms and improve quality of life with a minimum of treatment-related adverse effects.

Dr. Nguyen and colleagues summarize the new recommendations on the medical treatment of microscopic colitis in a report online November 13 in Gastroenterology. A supplementary technical review compiles the clinical evidence that forms the basis for the recommendations. The new guideline does not address the diagnosis, surgical management, or appropriateness of screening for associated autoimmune disorders in individuals with microscopic colitis.

Moderate-quality evidence supports the strong recommendation to treat patients with symptomatic microscopic colitis with budesonide.

Budesonide is recommended over treatment with mesalamine, bismuth salicylate, and prednisolone, all of which are recommended as possible second-line treatments when budesonide therapy is not feasible.

Based on low-quality evidence, the guidelines recommend against treatment with cholestyramine plus mesalamine (versus mesalamine alone), Boswellia serrata, and probiotics for the induction of clinical remission.

AGA recommends budesonide for maintenance of clinical remission for patients whose symptoms recur following discontinuation of induction therapy for microscopic colitis.

"Even budesonide, a corticosteroid with low systemic effects, can lead to bone loss with prolonged use and is expensive," Dr. Nguyen explained. "So you do want to avoid overtreatment. A third of patients only need an 8-week initial course of budesonide. Those whose symptoms recur after stopping therapy may require maintenance therapy for 6-12 months and should be treated with the lowest dose of budesonide that achieves clinical effect."

"When treating refractory cases, clinicians need to first consider potential coexisting conditions, such as celiac disease, that may have to be independently treated," Dr. Nguyen said. "Moreover, there are medications, such as NSAIDS, that may precipitate microscopic colitis, and these should be stopped if at all possible."

He added, "Immunosuppressant therapies such as azathioprine or anti-TNF agents have been reported in case series for the treatment of refractory microscopic colitis. Because the data supporting these treatments is very limited, they need to be considered on an individual basis."

Dr. Christopher Marshall from the University of Massachusetts in Worcester recently reviewed the etiology and treatment of microscopic colitis, including refractory disease.

He told Reuters Health by email, "Given that there are treatments available for microscopic colitis, physicians should note the importance of performing a colonoscopy in patients with chronic diarrhea. Physicians should also be aware that budesonide is efficacious in the management of these patients and should be used as a first-line agent."

"I think an important point to make is that these guidelines do not discuss how to manage refractory disease, which can pose significant therapeutic challenges," said Dr. Marshall, who did not work the new guidelines.

SOURCE: http://bit.ly/1RWrP82 and http://bit.ly/22dkuW6

Gastroenterol 2015.