Sulfasalazine and Other 5ASAs

Sulfasalazine has been used as the initial anti-inflammatory agent because of documented effectiveness in colonic idiopathic IBD, low cost, and a comparative lack of side effects. The usual dose of sulfasalazine is 2 to 4 g/d administered by mouth in divided doses with meals and at bedtime. The full dosage should be achieved slowly, starting with 1 tablet (0.5 g) daily and adding 1 tablet per day until the desired dosage is achieved. This may help avoid nausea and, perhaps, headaches. Conventional folic acid administration,

1 mg/d, seems reasonable. Abatement of diarrhea in 1 to

2 weeks with sulfasalazine as a single agent has been noted in approximately 50% of patients so treated. Patients have been continued on this agent or other 5-ASA drugs for 3 months and then tapered to a maintenance dose of 1 g twice a day. Some patients require higher doses of 5-ASA.

In persons with a history of sulfa allergy and those who

TABLE 87-1. Treatment Approach in Collagenous Lymphocytic Colitis

1. Eliminate secretagogues (lactose, caffeine, fat) and stop NSAIDs. Rule out thyroid dysfunction.

2.Trial of bismuth subsalicylate 262 mg 3 tablets in am, 2 tablets at noon, 3 tablets pm qd for 8 weeks

If no resolution,

3.5-ASA drugs ± antimotility agents X 1 to 2 months (mesalamine [Asacol] 800 to 1,200 mg tid, sulfasalazine [Azulfidine] 2 g bid)

If no resolution,

4.Add/substitute adrenocorticoid ± antimotility agents (prednisone 20 to 40 mg qd; budesonide 3 mg tid)

If no resolution,

5.Rule out small bowel disease, steatorrhea

If no resolution,

6. Immunosuppressive therapy (methotrexate) or surgery (diverting ileostomy versus colectomy)

ASA = acetylsalicylic acid; bid = twice daily; NSAID = nonsteroidal anti-inflammatory drug; qd =

every day; tid = 3 times daily.

have had adverse reactions to sulfasalazine (not infrequent circumstances) or are unresponsive, other 5-ASA mesalamine compounds may be used. Two oral mesalamine preparations are available (Asacol and Pentasa).

The usual dose of Asacol is 800 to 1,200 mg 3 times a day; the usual dose of Pentasa is 500 to 1,000 mg 2 to 3 times a day. Because the initial site of action of Pentasa is the small intestine, it may be less effective than other 5-ASA-continuing compounds. Patients who respond usually improve within 2 to 3 weeks. Maximum doses may be needed in some patients. Once symptomatic control is achieved, the dose may be gradually tapered, but most require the dose used for remission medicine. Because Dipentum (olsalazine) can cause net small bowel secretion, it is best avoided with microscopic colitis. Because collagenous lymphocytic colitis usually involves the proximal colon, 5-ASA enemas and suppositories are unlikely to be effective.

As a guide to therapy, repeat colonic biopsies can be taken after 2 to 3 months of treatment to assess resolution of collagen banding and the inflammatory infiltrate in the surface epithelium and lamina propria. If clinical and histologic benefits are evident, 6 to 12 months of empiric treatment has been given in an attempt to maximize his-tologic improvement. Subsequently, we have maintained the sulfasalazine or 5-ASA with continued attention to dietary factors and the use of antidiarrheal agents. Unfortunately, in some patients, diarrhea has recurred after lowering the dose or cessation of these agents.

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