Chronic colon inflammation calls for long-term oral steroid

DEAR DR.ROACH>> I was diagnosed with collagenous colitis nearly three years ago. I was prescribed budesonide, which brought it under control. I have tried getting off the medication several times, but my condition returns within a week or so. One 3-mg capsule keeps it under control. I am concerned about long-term use. A recent test showed that I have elevated liver enzymes. My doctor does not feel there is a connection, but I am concerned. I am 84 years old, in excellent health, taking no meds other than a very low dose of a blood pressure medicine (labetalol).

— M.T.

DEAR READER >> Collagenous colitis, a form of microscopic colitis, is a chronic inflammatory disease of the colon. The usual symptom is watery diarrhea, and it occurs most commonly in middleaged women. The diagnosis is made by biopsy of the colon.

Treatment with budesonide, a powerful oral steroid, is effective in 80 to 90 percent of people. Only about 10 to 20 percent of the budesonide is absorbed: The rest remains in the colon, where it is directly effective on the inflamed cells. Because it is so poorly absorbed, the systemic side effects are small.

The major problem I see with budesonide is that it is so expensive ($20 to $30 is the average wholesale price in the U.S. per pill) that many insurances do not cover it, and many people cannot afford it. I agree with your doctor that it is unlikely that the budesonide is the cause of your abnormal liver enzymes. Likewise, liver enzymes usually are normal in people with collagenous colitis.

Your doctor should take a look for other causes of abnormal liver enzymes, of which there are many. Medications and fatty liver disease are the two most frequent causes in my practice. However, some people diagnosed with collagenous colitis can later develop Crohn’s disease, and that often affects liver enzymes. There is a higher rate of both other autoimmune diseases and celiac disease alongside collagenous colitis, and these have the potential to cause abnormal liver enzymes as well.

DEAR DR. ROACH >> Our question has to do with the “normal ranges” for blood test results. Aren’t there standard normal ranges? We have had blood tests done at several different labs in the past few years. The last one said that the normal range for TSH is 0.35-5.50; two previous labs had different numbers. The American Association of Clinical Endocrinologists says the normal range for TSH is 0.3-3.0! Our doctor seems to have no opinion on the subject and goes with the latest lab’s “normal” range. What’s the story with lab blood test normal ranges?

— R.M.G.

DEAR READER >> The difference is that some laboratories use the standard definition of 95 percent of normal controls, and that gives the range of 0.35-5.5 (I’ve seen a top-normal range of 6 from some labs).

However, the American Association of Clinical Endocrinologists has written that in a group of people carefully chosen to include only those with no evidence of thyroid disease (recognizing that minimally symptomatic hypothyroidism is not uncommon), 95 percent of the group will have TSH levels below 3. This suggests that those with a TSH level between 3 and 5.5 may have asymptomatic or minimally symptomatic thyroid disease.

TSH levels vary during the day, and tend to increase as people get older. Not everyone with a slightly high TSH needs treatment. Experienced clinicians combine a careful history and exam with the laboratory findings to determine when to recommend thyroid hormone replacement; there isn’t a simple number cutoff.

Contact Dr. Roach at ToYourGoodHealth@med. cornell.edu.

To Your Good Health