Novel Use of Budesonide MMX in the Treatment of Lymphocytic Colitis

Abstract

Background: Microscopic colitis, in particular, lymphocytic colitis is a relatively common cause of chronic diarrhea. The incidence of lymphocytic colitis is reported up to 63.7 per 100,000 person-years. Unfortunately, limited pharmacologic interventions are available with durable remission. We present a case of lymphocytic colitis refractory to conventional therapy with efficacy with budesonide MMX therapy. Case Presentation: A 60-year-old Caucasian retired Army service member presented to a civilian Gastroenterology clinic with complaint of chronic diarrhea. He reported having up to 6-8 liquid bowel movements per day with Bristol 5-6 consistency for over 4 months with an associated 10 pound weight loss. He was initially discontinued on esomeprazole therapy and started on loperamide with no improvement in symptoms after 4 weeks. He was started on bismuth subsalicylate for another 4 weeks with minimal to no response. He attempted a short course of oral prednisone therapy but was intolerant due to significant side effects including headaches and migraines. He underwent an EGD and repeat colonoscopy for second opinion evaluation. Random duodenal biopsies were negative for enteritis (to include celiac) and repeat colonic biopsies with persistent lymphocytic colitis but negative for infectious agents and/or inflammatory bowel disease. Patient was started on budesonide MMX therapy daily for 2 months. He noted complete resolution of symptoms with normalization of bowels within 1 week of therapy. He remained asymptomatic at follow-up 3 months after therapy completion. Discussion: Lymphocytic colitis is a common colonic disorder associated with chronic watery diarrhea. When medication side effects and food-related diarrhea is eliminated, pharmacological options are limited with short rates of durable remission. Budesonide MMX is a novel therapy option due to its formulation and colonic delivery design allowing high rates of colonic penetration with minimal systemic absorption.