When disease extent is not always a key parameter: Management of refractory ulcerative proctitis

Abstract

Background: Patients with ulcerative proctitis represent a sub-group of ulcerative colitis patients with specific characteristics. Disease-related symptoms, endoscopic findings and patient's personality perspectives create a difficult-to-assess condition in certain cases.

Objectives: To summarize available evidence on the management of refractory ulcerative proctitis and provide insights in treatment options.

Results: /Conclusion: Topical therapy plays a central role due to the location of the disease. However, well-established treatment options may become exhausted in a considerable proportion of ulcerative proctitis patients, indicating the need to advance to more potent therapies in order to induce and maintain clinical response and remission in these refractory cases. Systemic corticosteroids, thiopurines, calcineurin inhibitors, biologic agents and small molecules have all been tested with variable success rates. Investigational interventions as well as surgical procedures are kept as the ultimate resort in multi-treatment resistant cases. Identifying early prognostic factors that herald a disabling disease progression will help in optimizing treatment and avoiding surgery.

Keywords: 5-ASAs, 5-aminosalicylates; CD, Crohn's disease; CS, Corticosteroids; IBD, inflammatory bowel disease; Inflammatory bowel disease; Proctitis; UC, ulcerative colitis; UP, ulcerative proctitis; Ulcerative colitis.

Fig. 1

Treatment algorithm of refractory ulcerative proctitis. 5-ASA, 5-aminosalicylates; IPAA, ileal-pouch anal anastomosis; NSAIDS, non-steroidal anti-inflammatory drugs, Dashed arrows and box lining: limited evidence ∗ these steps can mutually change based on evidence for more extensive UC, UP specific profile characteristics, safety issues, treating physician's or patient's preference or local reimbursement policy.