AGA Releases Guideline for Management of Moderate to Severe UC

The American Gastroenterological Association (AGA) has developed a clinical practice guideline for the medical management of patients with moderate to severe ulcerative colitis (UC). The guideline also includes recommendations on the medical management of adult hospitalized patients with acute severe ulcerative colitis (ASUC).

Specifically, the guideline authors focused on immunomodulators, biologics, and small molecules for induction and maintenance of remission in moderate to severe UC and on decreasing the risk of colectomy in ASUC.

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To develop the guideline, the panel implemented a Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. By doing this, the panel was able to make 10 recommendations for the management of patients with moderate to severe UC.

The one strong recommendation is that adult outpatients with moderate to severe UC use infliximab, adalimumab, golimumab, vedolizumab, tofacitinib, or ustekinumab over no treatment.

The other 9 recommendations are conditional and include the following:

• The AGA suggests prescribing infliximab or vedolizumab rather than adalimumab for induction of remission among patients who are naive to biologic agents.
• The AGA suggests against the use of thiopurine monotherapy for induction of remission if the moderate-severe UC is active. If the moderate to severe UC is in remission, use thiopurine monotherapy rather than no treatment for maintenance of remission.
• The AGA suggests against methotrexate monotherapy for induction or maintenance of remission.
• The AGA suggests biologic monotherapy rather than a thiopurine monotherapy for induction of remission.
• Rather than a gradual step-up after failure of 5-aminosalicylates, the AGA suggests early use of biologic agents with or without immunomodulator therapy.

The panel also developed 3 conditional recommendations for the management of adult hospitalized patients with ASCU:

• The AGA suggests using intravenous methylprednisolone dose equivalent of 40 to 60 mg/d rather than higher-dose intravenous corticosteroids.
• The AGA suggests against adjunctive antibiotics for patients without infections.
• The AGA suggests infliximab or cyclosporine for patients with ASCU that is refractory to intravenous corticosteroids.

The guideline authors also highlighted several knowledge gaps, including whether adult outpatients with moderate to severe UC in remission should use biologic monotherapy vs thiopurine monotherapy for maintenance of remission. Another identified knowledge gap is whether hospitalized adult patients with ASCU that is refractory to intravenous corticosteroids, who are being treated with infliximab, should routinely use intensive or standard infliximab dosing.

“With the increasing number of different drug classes available to treat UC, there is a clear need for identifying biomarkers predictive of response to individual therapies, to facilitate optimal positioning of therapies,” the guideline authors wrote.

—Colleen Murphy

Reference:

Feuerstein JD, Isaacs KL, Schneider Y, Siddique SM, Falck-Ytter Y, Singh S; American Gastroenterological Association Institute Clinical Guidelines Committee. AGA clinical practice guidelines on the management of moderate to severe ulcerative colitis [published online January 13, 2020]. Gastroenterology. doi:10.1053/j.gastro.2020.01.006.