Ulcerative Colitis Guidelines

Updated: Jul 26, 2019
  • Author: Marc D Basson, MD, PhD, MBA, FACS; Chief Editor: BS Anand, MD  more...
  • Print
Guidelines

American College of Gastroenterology Guidelines

The American College of Gastroenterology (ACG) published recommendations on ulcerative colitis (UC) in adults in March 2019. [103, 104]  The focus of management has shifted from symptom-based treatment to symptom management and mucosal healing. The ACG guideline's strong recommendations are outlined below. [103]

Diagnosis, assessment, and prognosis

Stool testing is recommended to exclude Clostridioides difficile when UC is suspected.

Serologic antibody testing is not recommended for the following:

  • To establish or exclude a diagnosis of UC
  • To determine the prognosis of UC

Goals for managing patients with UC

Treat patients with UC to achieve mucosal healing (ie, resolution of inflammatory changes [Mayo endoscopic subscore 0 or 1]) to increase the likelihood of sustained steroid-free remission and prevent hospitalizations and surgery.

UC management

Induction and maintenance of remission in mildly active UC

Patients with, or who previously had, mildly active ulcerative proctitis are recommended to receive rectal (PR) 5-aminosalicylate (5-ASA) therapies at a dose of 1 g/d to induce or maintain remission.

To induce remission in patients with mildly active left-sided UC:

  • Rectal 5-ASA enemas at a dose of at least 1 g/d are preferred over rectal steroids.
  • In the setting of intolerance or nonresponse to oral (PO) and PR 5-ASA at appropriate doses (PO: ≥2 g/d; PR: ≥1 g/d), use PO budesonide multi-matrix (MMX) 9 mg/d.

Patients with mildly active extensive UC are recommended to receive PO 5-ASA at a dose of at least 2 g/d to induce remission.

Patients with UC of any extent whose condition fails to respond to 5-ASA therapy are recommended to receive PO systemic corticosteroids to induce remission.

Patients with mildly to moderately active UC refractory to PO 5-ASA are recommended to additionally receive budesonide MMX 9 mg/d to induce remission.

Patients with mildly to moderately active UC of any extent using 5-ASA to induce remission are recommend to receive either once-daily or more frequently dosed PO 5-ASA based on patient preference to optimize adherence, as efficacy and safety are no different.

Patients with mildly active left-sided or extensive UC are recommend to receive at least 2 g/d of PO 5-ASA therapy for maintenance of remission.

Systemic corticosteroids are not recommended to maintain remission in patients with UC.

Management of moderately to severely active UC

Induction of remission

For moderately active UC, PO budesonide MMX is recommended to induce remission.

For moderately to severely active UC of any extent, PO systemic corticosteroids are recommended to induce remission.

To induce remission in patients with moderately to severely active UC, note the following:

  • Monotherapy with thiopurines or methotrexate is  not recommended.
  • Anti-tumor necrosis factor (TNF) therapy using adalimumab, golimumab, or infliximab is recommended.
  • When infliximab is used as induction therapy, combination therapy with a thiopurine is recommended.
  • Vedolizumab or tofacitinib (tofacitinib: 10 mg PO twice daily × 8 wk) is recommended (either agent is also recommended when anti-TNF therapy has failed previously).

Maintenance of remission in those with previously moderately to severely active UC

Systemic corticosteroids are not recommended to maintain remission in patients with UC.

Continue anti-TNF therapy using adalimumab, golimumab, or infliximab to maintain remission after anti-TNF induction in patients with previously moderately to severely active UC.

Continue vedolizumab to maintain remission in patients with previously moderately to severely active UC now in remission after vedolizumab induction.

Continue tofacitinib to maintain remission in patients with previously moderately to severely active UC now in remission after tofacitinib induction.

Management of hospitalized patients with acute severe UC (ASUC)

Apply deep venous thrombosis (DVT) prophylaxis to prevent venous thromboembolism (VTE).

Test for C difficile infection (CDI).

In the setting of ASUC and concomitant CDI, treat CDI with vancomycin instead of metronidazole.

Routine use of broad-spectrum antibiotics is not recommended to manage ASUC.

Use methylprednisolone 60 mg/d or hydrocortisone 100 mg 3 or 4 times daily to induce remission.

In the setting of ASUC with inadequate response to intravenous corticosteroids (IVCS) by 3-5 days, medical rescue therapy with infliximab or cyclosporine is recommended.

When remission is achieved with infliximab treatment, maintain remission with infliximab.

Colorectal cancer prevention in UC

When using standard-definition colonoscopes in those with UC undergoing surveillance, dye spray chromoendoscopy with methylene blue or indigo carmine is recommended to identify dysplasia.

Next:

American Gastroenterological Association Guidelines

The American Gastroenterological Association (AGA) released new guidelines on the management of mild-to-moderate ulcerative colitis (UC) in February 2019, [105]  with a focus on the use of oral (PO) and topical 5-aminosalicylates (5-ASA) agents, rectal (PR) corticosteroids, and PO budesonide. [105, 106]  

Strong recommendations

Patients with extensive mild-moderate UC: The AGA recommends using either standard-dose mesalamine (2-3 g/d) or diazo-bonded 5-ASA rather than low-dose mesalamine, sulfasalazine, or no treatment. (Patients already on sulfasalazine in remission or patients with prominent arthritic symptoms may reasonably choose sulfasalazine 2-4 g/d if alternatives are cost-prohibitive, albeit with higher rate of intolerance.)

Patients with mild-moderate ulcerative proctitis who choose rectal therapy over oral therapy: The AGA recommends using mesalamine suppositories.

Conditional recommendations

Patients with extensive or left-sided mild-moderate UC: The AGA suggests adding rectal mesalamine to oral 5-ASA.

Patients with mild-moderate UC with a suboptimal response to standard-dose mesalamine or diazo-bonded 5-ASA or with moderate disease activity: The AGA suggests using high-dose mesalamine (>3 g/d) with rectal mesalamine.

Patients with mild-moderate UC being treated with oral mesalamine: The AGA suggests using once-daily dosing rather than multiple times per day dosing.

Patients with mild-moderate UC: The AGA suggests using standard-dose oral mesalamine or diazo-bonded 5-ASA, rather than budesonide MMX (Multi-Matrix System) or controlled ileal release budesonide for induction of remission.

Patients with left-sided mild-moderate ulcerative proctosigmoiditis or proctitis: The AGA suggests using mesalamine enemas (or suppositories) rather than oral mesalamine. (Patients who have a higher value for convenience of oral medication administration and a lower value on effectiveness could reasonably choose oral mesalamine.)

Patients with mild-moderate ulcerative proctosigmoiditis who choose rectal therapy over oral therapy: The AGA suggests using mesalamine enemas rather than rectal corticosteroids. (Patients who place a higher value on avoiding difficulties associated with mesalamine enemas and a lower value on effectiveness may reasonably select rectal corticosteroid foam preparations.)

Patients with mild-moderate ulcerative proctosigmoiditis or proctitis being treated with rectal therapy who are intolerant of or refractory to mesalamine suppositories: The AGA suggests using rectal corticosteroid therapy rather than no therapy for induction of remission.

Patients with mild-moderate UC refractory to optimized oral and rectal 5-ASA, regardless of disease extent: The AGA suggests adding either oral prednisone or budesonide MMX.

No recommendations

The AGA makes no recommendations for the use of probiotics in those with mild-moderate UC, nor for the use of curcumin in patients with mild-moderate UC despite 5-ASA therapy.

In patients with mild–moderate UC without Clostridium difficile infection, the AGA recommends fecal microbiota transplantation be performed only in the context of a clinical trial.

Previous