Adrenocorticoids

If no clinical improvement is noted after 2 to 4 weeks of sulfasalazine and/or 5-ASA therapy, adrenocorticoid medication is added or substituted. Most of our patients with collagenous lymphocytic colitis have received prednisone. Dramatic resolution of diarrhea in 80 to 90% of individuals has been noted within 5 days of the start of treatment. Additionally, in patients with lymphocytic colitis, histologic improvement has been seen. Disappearance of the collagen banding and repair of the surface epithelial damage have also been documented in those with collagenous colitis.

Most individuals have been treated as outpatients with prednisone in a morning oral dosage of 20 to 40 mg. An occasional patient with more than 2 L of stool a day has been hospitalized and treated with intravenous pred-nisolone, 60 mg/d, or hydrocortisone. Once control of diarrhea is achieved, patients have been maintained on 20 to 30 mg of prednisone for 3 months, and repeat colonic biopsies are obtained. After 3 months, we have attempted to change to an alternate-day dose or to discontinue prednisone. However, recurrence of diarrhea has been noted in most patients. In these cases, small doses of 10 to 15 mg of prednisone daily or alternate-day steroids have been administered with success. In addition, other antidiarrheal agents described above have been added to the regimen to minimize prednisone dosage and adverse side effects.

Recently, budesonide (Entocort), an oral medication with topical corticoid released in the small intestine and ascending colon, has been incorporated in the treatment of collagenous lymphocytic colitis. Budesonide has a topical effect and a low bioavailability of about 10%.

This drug is therapeutically similar to prednisone, but with fewer side effects. In a randomized, double-blind, placebo-controlled trial, 20 patients with collagenous colitis were randomized to either placebo or budesonide (Entocort) 9 mg/d for 8 weeks. Clinical improvement was achieved in 10 (100%) patients receiving budesonide compared with 2 (20%) patients in the placebo group (p < .001). The histologic inflammation grade in the sigmoid mucosa and the thickness of the collagen layer were significantly reduced (p < .02) in those receiving budesonide. Symptoms relapsed in 8 of 10 patients within 8 weeks after discontinuation of budesonide, suggesting that most may need sustained treatment to remain asymptomatic. Further studies and long-term follow-up are warranted.*

In our experience with the above therapeutic approach, symptomatic improvement has occurred in most patients, and histologic improvement has occurred in some. However, in only a few patients has total histologic reversal occurred, even in those who are asymptomatic for many months. Therefore, questions still remain as to the duration of therapy and the utility of histologic appearances as a guide to treatment.

Constipation Prescription

Constipation Prescription

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