AGA Releases Guidelines on Ulcerative Colitis Management

A new clinical guideline from the American Gastroenterological Association (AGA) spotlights the best therapies to manage patients with mild-to-moderate ulcerative colitis (UC).

“Management of patients with ulcerative colitis has become increasingly complex with the number of available drugs, formations, routes of administration, extent of disease involvement, and severity of disease,” Dr. Joseph Feuerstein, AGA expert and author on the guidelines, told Gastroenterology Consultant. “While many practitioners have their preferred treatment algorithms, this guideline provides the practitioner with the evidence-based approach to treat their patients.”

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The guidelines were developed by the AGA Institute’s Clinical Guidelines Committee, accompanied by a technical review that compiled clinical evidence based on which the recommendations were framed. They were approved by the AGA Governing Board.

“This is the first guideline that we have which is based on GRADE methodology that specifically focuses on an evidence-based approach to the treatment of patients with mild-moderate inflammatory bowel disease,” Feuerstein, who is an assistant professor of medicine at Harvard Medical School, said. “The technical review provides the evidence to answer the 12 PICO questions focused on the different treatment options for these patients. The guideline takes these evidence profiles and created 13 recommendations to help provide evidence based high quality care to patients with [mild-to-moderate] ulcerative colitis.”

The strongest recommendations, based on high-quality evidence, included:

• patients with extensive mild-moderate UC should be prescribed either standard dose mesalamine (2-3, grams, a day) or diazo-bonded 5-ASA, as opposed to low dose mesalamine, sulfasalazine, or no treatment; and
• patients with mild-to-moderate ulcerative proctitis who choose rectal therapy over oral therapy should use mesalamine suppositories.

Some conditional recommendations, based on low-quality evidence, included:

• patients with extensive or left-sided mild-to-moderate UC should receive rectal mesalamine and oral 5-ASA;
• patients with mild-to-moderate ulcerative proctosigmoiditis who choose rectal therapy over oral therapy should receive mesalamine enemas over rectal corticosteroids; and
• patients with mild-to-moderate UC who receive oral mesalamine as treatment should use once-daily dosing rather than multiple times per day dosing.

“Providing practitioners with a clearer summary of the evidence and the formulation of management recommendations from this evidence should provide the clinical community and patients with inflammatory bowel disease high value evidence-based quality care,” Feuerstein said.

The guidelines provided no treatment recommendations for probiotics or curcumin due to a knowledge gap.

“The guideline acknowledges the need for more evidence and studies surrounding the use of probiotics, curcumin, and fecal microbiota transplantation,” Feuerstein said. “Additionally, we need a better understanding of who is high risk of disease progression and at risk of colectomy so that we can determine when is the appropriate time to escalate to an immunomodulatory, biologic or small molecule drug in these patients.”

See all the guidelines’ recommendations here.

—Colleen Murphy

References:

1. Ko CW, Singh S, Feuerstein JD, et al. American Gastroenterological Association Institute guideline on the management of mild-to-moderate ulcerative colitis. [published online December 18, 2018]. Gastroenterology. https://doi.org/10.1053/j.gastro.2018.12.009.

2. New guideline provides recommendations for the treatment of mild-to-moderate ulcerative colitis [press release]. Bethesda, MD: American Gastroenterological Association; January 9, 2019. https://www.gastro.org/press-release/new-guideline-provides-recommendations-for-the-treatment-of-mild-to-moderate-ulcerative-colitis. Accessed January 11, 2019.