Turning off the Faucet: Novel Therapy for 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 had an associated history of GERD and hemochromatosis. He reported having up to 6-8 liquid bowel movements per day with Bristol 5-6 consistency for over 4 months. He reported having associated mild weight loss of 10 pounds. He reported no exacerbation of symptoms with lactose products and/or gluten-containing products. He underwent a colonoscopy with reports demonstrating a normal mucosal appearance but with random biopsies consistent with lymphocytic colitis. 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 (Figures 1,2). All specimens were reviewed by a gastro-pathologist.Figure 1Figure 2Patient 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 followup 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.