The American College of Gastroenterology published 2019 clinical guidelines for ulcerative colitis (UC) in adults, focusing on diagnosis, treatment, and management.

The guidelines, published in the American Journal of Gastroenterology, include key concept statements, recommendations, and summaries of evidence.

Strong recommendations with moderate- or high-quality evidence are provided here.

Management of UC:

Induction of remission in mildly active UC

  • Rectal 5-aminosalicylate therapies are recommended in patient with mildly active ulcerative proctitis, at a dose of 1 g/d (high quality).
  • Rectal 5-aminosalicylate enemas at a dose of 1 g/d are recommended for patients with mildly active left-sided UC and are preferred to rectal steroids (moderate quality).
  • For patients with mildly active left-sided UC who do not respond to combination treatment (described earlier), oral budesonide multimax at a dose of 9 mg/d is recommended (moderate quality).
  • The addition of budesonide multimax 9 mg/d is recommended for patients with mildly to moderately active UC who do not response to oral 5-aminosalicylate (moderate quality).
  • Once-daily and more frequently dosed oral 5-aminosalicylate do not vary in efficacy and safety; therefore, patients with mildly to moderately active UC should be dosed according to patient preference to optimize adherence (moderate quality).

Maintenance of remission in patients with previously mildly active UC

  • Rectal 5-aminosalicylate at a dose of 1 g/d is recommended (moderate quality).
  • For patients with mildly active left-sided or extensive UC, oral 5-aminosalicylate therapy dosed at least 2 g/d is recommended (moderate quality).
  • Systemic corticosteroids are not recommended for maintenance of remission (moderate quality).

Management of Moderately to Severely Active UC:

Induction of remission:

  • Oral budesonide multimax is recommended for patients with moderately active UC (moderate quality).
  • Oral systemic corticosteroids are recommended for patients with moderately to severely active UC of any extent (moderate quality).
  • Anti-tumor necrosis factor (TNF) therapy using adalimumab, golimumab, or infliximab is recommended to induce remission (high quality).
  • Combination therapy with thiopurine is recommended for patients with moderately to severely active UC who use infliximab as an induction therapy (moderate-quality evidence for azathioprine).
  • Vedolizumab is strongly recommended for induction of remission (moderate quality) and for individuals who have previously failed anti-TNF therapy (moderate quality).
  • The American College of Gastroenterology strongly recommends tofacitinib 10 mg orally twice daily for 8 weeks (moderate quality).
  • Tofacitinib is recommended for patients who previously failed anti-TNF therapy (moderate quality).

Maintenance of remission in patients with previously moderately to severely active UC:

  • The American College of Gastroenterology recommends against systemic corticosteroids for maintenance of remission (moderate quality).
  • The continuation of anti-TNF therapy using adalimumab, golimumab, or infliximab is recommended to maintain remission after anti-TNF induction (moderate quality).
  • Continuing vedolizumab to maintain remission after induction with vedolizumab is recommended (moderate quality).
  • Continuing tofacitinib to maintain remission after induction with tofacitinib is recommended (moderate quality).

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Management of the Hospitalized Patient With Acute Severe UC:

  • Patients with acute severe UC should be tested for Clostridioides difficile infection (moderate quality).
  • Patients with acute severe UC who do not respond well to intravenous corticosteroids by 3 to 5 days should undergo medical rescue therapy with infliximab or cyclosporine (moderate quality).
  • Those who achieve remission with infliximab treatment should use the same agent to maintain remission (moderate quality).

“The appropriate management of patients with UC involves successful induction of both clinical and endoscopic remission, followed by the use of a steroid-free maintenance strategy,” noted the authors of the guidelines. “Choice of therapy for UC is based on activity, severity, extent of inflammation, and prognostic factors and may include oral, topical (rectal), or systemic therapies, as well as surgery. When possible and appropriate based on individual clinical factors, organ-specific treatments can be used before systemic therapies.”

Reference

Rubin DT, Ananthakrishnan AN, Siegel CA, Sauer BG, Long MD. ACG clinical guideline: ulcerative colitis in adults. Am J Gastroenterol. 2019;114:384-413.