Approximately 20% of patients may have a spontaneous remission without specific therapy. Medication is indicated only if discontinuing dietary components or medications considered possibly responsible (NSAID, SSRI...) for the illness fails to alleviate the symptoms. As above, treatment is initiated with the least toxic effective agents. If a patient fails to respond to simple antidiarrheal drugs, anti-inflammatory or immunosuppressive medications may be required.
Diet includes:
1. Patients should avoid or eliminate possible secretagogues, such as caffeine, and, when appropriate, lactose-containing products, and
2. A low-fat diet is advisable if steatorrhea is documented.
If diet doesn't help you can require medical therapy. Generally, 1 month should be allowed before deeming a particular medication ineffective in the treatment lymphocytic colitis. One possible treatment algorithm is as follows:
1. First line: Loperamide (Imodium AD) or diphoxylate/atropine (Lomotil);
2. Second line: Bismuth subsalicylate (effective in up to 90% of patients); mesalamine (LIALDA), or cholestyramine (especially if bile acid malabsorption is documented);
3. Third line: If patient is still not responding, a 2-month course of budesonide or a 2-week course of high-dose prednisone (60-80 mg/d) before tapering can be prescribed.
4. Fourth line: Some refractory cases may benefit from azathioprine or 6-mercaptopurine, but responses often take months to occur.
Patients who respond to treatment, but experience a recurrence, will often respond again to the same previously effective medication. If colitis is refractory to continued medical therapy or if effective medication cannot be tolerated, surgery (colectomy or ileostomy) might be the only effective therapy; however, this seldom is necessary.