Treatment of Ulcerative Proctitis
A question was posted by Jack as to how to manage symptoms of ulcerative proctitis (UP) when titrating steroids. While I cannot provide advice specific to individual cases through this blog, there are some generalities regarding treatment of UP that can be discussed.
Treatment of active UP
UP refers to inflammation solely involving the rectum (up to 10-15cm from the anus). Because UP is limited to a very small portion at the end of the colon, suppository and enema therapy is usually first line. Rectal 5-ASA medications (mesalamine) are an appropriate choice when initiating therapy for UP. Suppositories supply medication to the last 10-15cm of the rectum, while enemas (liquid, gel, or foam) deliver medication further up the left colon. Most patients find the suppositories easiest to use. If symptoms persist after 4 weeks of daily rectal therapy, there may be benefit to adding oral 5-ASAs 2.4- 4.8 grams/day. Alternatively, some patients may benefit from adding or switching to a rectal steroid suppository or foam. It should be noted that rectal steroids are absorbed systemically and if used on a regular basis, one can develop steroid-related side effects. As such, rectal steroids are appropriate for inducing remission of disease, but their use as a maintenance agent should be avoided.
Oral steroids are reserved for patients not responding to rectally administered 5-ASAs/and or rectal steroids or to oral 5-ASA medicines. Treatment with prednisone 40mg daily usually results in quick resolution of symptoms. High doses of steroids are used for 1-2 weeks until symptoms improve and are then tapered 5-10 mg per week. The rate at which steroids are decreased depends on a patient's symptoms and overall clinical picture. Slowing the taper or decreasing by 2.5mg increments may help some patients. After decreasing doses, it may take time for the body to adjust. If oral steroids are used, it is recommended that patients continue their prior treatment (rectal 5-ASA/steroid +/- oral 5-ASA) in addition to the steroids. The goal is to use these medications to maintain remission once the prednisone is tapered off.
Treatment of UP refractory to 5-ASA medicines and oral steroids
When patients continue to experience symptoms despite the addition of oral steroids, there are a number of considerations:
1) Is there a gastrointestinal infection present resulting in symptoms?
2) Are patients taking non-steroidal medications like ibuprofen? These medications can worsen
IBD and patients are advised not to take them.
3) Did the symptoms worsen after the addition of a 5-ASA medicine? Some patients will have a
hypersensitivity reaction to this class of medicines which resolves when the medicine is
stopped. The symptoms of a hypersensitivity reaction are usually abdominal pain and
diarrhea.
4) Did the patient just stop smoking cigarettes? Smoking cessation has been associated with
UC.
5) Were the rectal therapies stopped or not been given consistently? Discontinuing rectal
therapies may make disease worsen.
With regard to treatment options, there is no one right answer. While there is insufficient evidence for the routine use of antibiotics in UP and UC, there are reported cases of people with refractory disease improving on antibiotics. As such, a trial of an antibiotic such as ciprofloxacin or metronidazole may not be unreasonable. For ex-smokers, anecdotes of using nicotine patches have suggested they may be of benefit in this subgroup. Finally, escalation of therapy to azathioprine/6-mercaptoputrine, cyclosporine, or infliximab may be considered.