Shaadi Abughazaleh, MD
Houston, Texas
Shaadi Abughazaleh, MD, Kerri Glassner, DO, Amanda Wilhite, PA-C, Bincy Abraham, MD, FACG
Houston Methodist Hospital, Houston, TX
Introduction: Lymphocytic colitis is a chronic inflammatory disease manifesting with chronic, watery, non-bloody diarrhea. Patients have a normal appearing colon with biopsies showing histological changes. Medications are believed to be typical culprits, however data on causality is lacking. Treatment is focused on symptom management, however in refractory cases budesonide has been shown to provide both clinical and histological remission. There is limited data to guide practitioners for patients who fail to have improvement on budesonide. We present a case of a female who failed budesonide and was treated with ustekinumab for her lymphocytic colitis.
Case Description/Methods: A 54 year old woman with a history of indeterminate colitis presented with diarrhea, severe fatigue, and abdominal pain in January 2019. She was presumably diagnosed with ulcerative colitis (UC) in 2000 but without evidence of endoscopic or histologic findings. Her diagnosis was subsequently changed to Crohn’s disease (CD) in 2008 based on serologic markers alone again without evidence of endoscopic inflammation. Previous colonoscopy in 2015 showed endoscopically normal mucosa with biopsies suggestive of lymphocytic colitis (Image 1). Due to her symptoms, she was started on ustekinumab. At that time, ustekinumab levels were found to be 9.9 (Inform Tx). At presentation, she was on ustekinumab q8 weeks, budesonide, and methotrexate. She was started on azathioprine while continuing budesonide and stopping methotrexate. After 3 months (March, 2019), her symptoms persisted, so her ustekinumab level was checked and was found to be low at 2.2. Therefore, she received a booster 90mg SQ dose of ustekinumab. Budesonide was discontinued. Colonoscopy in May 2019 revealed endoscopic and histologic remission of the lymphocytic colitis.
Discussion: First line treatment options for lymphocytic colitis include avoidance of culprit medications and symptomatic treatment. In patients with persistent symptoms, budesonide has been effective in inducing clinical and histological remission in 6 weeks. In cases refractory to budesonide, there is very limited data on alternative treatment options. Although immunomodulators and biologics have been used for CD and UC, their utility in microscopic colitis remains unknown. Case reports have described varying success using agents such as azathioprine, infliximab, adalimumab, and mercaptopurine. We present a case of lymphocytic colitis successfully treated with a combination of ustekinumab and azathioprine.
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Citation: Shaadi Abughazaleh, MD, Kerri Glassner, DO, Amanda Wilhite, PA-C, Bincy Abraham, MD, FACG. P0548 - A STELLAR CASE OF STELARA IN THE TREATMENT OF LYMPHOCYTIC COLITIS. Program No. P0548. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.