New Guideline Released for Management of Mild-to-Moderate Ulcerative Colitis

The American Gastroenterological Association (AGA) recently released a new clinical guideline for the treatment of mild-to-moderate ulcerative colitis (UC). The guideline, which was published in Gastroenterology, focuses on the use of both oral and topical 5-aminosalicylates (5-ASA) medications, rectal corticosteroids, and oral budesonide.

Most patients with UC experience mild-to-moderate disease activity with periods of remission and relapse. Because of this, optimal management of UC is essential to minimize the risk of relapse, disease progression, complications, and the need for immunosuppressive therapy.

According to the AGA, mild-to-moderate UC is defined as patients with fewer than 4 to 6 bowel movements per day, mild or moderate rectal bleeding, absence of constitutional symptoms, low overall inflammatory burden, and the absence of features suggestive of high inflammatory activity. However, patients who have more frequent bowel movements, more prominent rectal bleeding, or a greater overall inflammatory burden should be considered to have moderate disease.

Key recommendations outlined in the clinical guideline are as follows:

• Use either standard dose mesalamine (2-3 grams per day) or diazo-bonded 5-ASA rather than low-dose mesalamine, sulfasalazine, or no treatment in patients with extensive mild-moderate UC (strong recommendation, moderate quality evidence).
• Add rectal mesalamine to oral 5-ASA in patients with extensive or left-sided mild-moderate UC (conditional recommendation, moderate quality evidence).
• Use high-dose mesalamine (>3 grams per day) with rectal mesalamine in patients with mild-moderate UC with suboptimal response to standard-dose mesalamine or diazo-bonded 5-ASA or with moderate disease activity (conditional recommendation, moderate quality evidence).
• In patients with mild-moderate UC being treated with oral mesalamine, use once-daily dosing rather than multiple times per day dosing (conditional recommendation, moderate quality evidence).
• In patients with mild-moderate UC, use standard-dose oral mesalamine or diazo-bonded 5-ASA rather than budesonide MMX or controlled ileal-release budesonide for induction of remission (conditional recommendation, low quality of evidence).
• In patients with mild-moderate ulcerative proctosigmoiditis or proctitis, use mesalamine enemas (or suppositories) rather than oral mesalamine (conditional recommendation, very-low-quality evidence).
• In patients with mild-moderate ulcerative proctosigmoiditis who choose rectal therapy over oral therapy, use mesalamine enemas rather than rectal corticosteroids (conditional recommendation, moderate-quality evidence).
• In patients with mild-moderate ulcerative proctitis who choose rectal therapy over oral therapy, use mesalamine suppositories (strong recommendation, moderate-quality evidence).
• In patients with mild-moderate ulcerative proctosigmoiditis or proctitis being treated with rectal therapy who are intolerant of or refractory to mesalamine suppositories, use rectal corticosteroid therapy rather than no therapy for induction of remission (conditional recommendation, low-quality evidence).
• In patients with mild-moderate UC refractory to optimized oral and rectal 5-ASA, regardless of disease extent, add either oral prednisone or budesonide MMX. (conditional recommendation, low-quality evidence).
• In patients with mild-moderate UC, AGA makes no recommendation for use of probiotics (no recommendation, knowledge gap).
• In patients with mild-moderate UC despite 5-ASA therapy, AGA makes no recommendation for use of curcumin (no recommendation, knowledge gap).
• In patients with mild-moderate UC without Clostridium difficile infection, AGA recommends fecal microbiota transplantation be performed only in the context of a clinical trial (no recommendation for treatment of ulcerative colitis, knowledge gap).

Patients who do not effectively respond to the therapies outlined in the guidelines may need treatment with systemic corticosteroids, immunomodulators and/or biologic therapies, according to the AGA.

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References

Ko CW, Singh S, Feuerstein JD, et al. American Gastroenterological Association Institute guideline on the management of mild-to-moderate ulcerative colitis. Gastroenterology. 2019. Doi: https://doi.org/10.1053/j.gastro.2018.12.009

New guideline provides recommendations for the treatment of mild-to-moderate ulcerative colitis [news release]. American Gastroenterological Association’s website. https://www.gastro.org/press-release/new-guideline-provides-recommendations-for-the-treatment-of-mild-to-moderate-ulcerative-colitis. Accessed January 10, 2019.