Induction therapy for unresponsive ulcerative proctitis or distal colitis in adults

If clinical response to initial therapy for ulcerative proctitis or distal (left-sided) colitis is inadequate, add an oral corticosteroid. Use:

prednisolone (or prednisone) 40 to 50 mg orally, daily in the morning until clinical response, then taper over 5 to 8 weeks to stop. prednisolone prednisolone prednisolone

For patients with a history of adverse reactions to systemic corticosteroids or precautions to their use (eg diabetes), consider using the multimatrix system (MMX) preparation of budesonide (eg Cortiment)¹ ² Lichtenstein, 2015 Sandborn, 2012 Travis, 2014.

If clinical response to initial therapy in combination with an oral corticosteroid is inadequate, add rectal tacrolimus³. UseFehily, 2020 Salem, 2021:

tacrolimus 2 mg rectally, daily in the evening for at least 4 weeks and until clinical response. Dose frequency can then be reduced according to symptom response. tacrolimus tacrolimus tacrolimus

For patients who require repeated or prolonged courses of oral corticosteroids or tacrolimus, consider starting azathioprine or mercaptopurine.

Patients with unresponsive distal colitis may be constipated proximal to the inflamed mucosa; symptoms improve if constipation is treated (see Functional constipation in adults).

¹ At the time of writing, the multimatrix system (MMX) preparation of budesonide (eg Cortiment) is not available on the Pharmaceutical Benefits Scheme (PBS). See the PBS website for current information.Return

² Other oral preparations of budesonide (eg Entocort, Budenofalk) are not interchangeable with the MMX formulation (eg Cortiment), because they have different release characteristics.Return

³ At the time of writing, rectal tacrolimus preparations (suppositories, enemas, paste) are not registered by the Australian Therapeutic Goods Administration (TGA) but are available from hospital pharmacy departments or compounding pharmacies.Return