Guidelines

AGA releases new ulcerative colitis management guidelines

Raymond Cross, MD
Raymond K. Cross

The American Gastroenterological Association has released new clinical guidelines on the management of patients with mild to moderate ulcerative colitis, focusing on the use of both oral and topical 5-aminosalicylates, rectal corticosteroids and oral budesonide.

“Mild to moderate ulcerative colitis really [constitutes] the largest group of patients that we see with that disorder,” Raymond K. Cross, MD, MS, director of the Inflammatory Bowel Disease Program at University of Maryland School of Medicine, and guideline co-author, told Healio Gastroenterology and Liver Disease. “These are patients that are primarily treated with 5-aminosalicylates, and that’s the vast majority of what is seen in the community.”

Developed by the AGA Institute’s Clinical Guidelines Committee, the guidelines are accompanied by a technical review that includes a compilation of the evidence on which the recommendations were formulated.

The guideline included two “strong” recommendations that were supported by a “moderate” amount of quality evidence:

  • Standard-dose mesalamine (2 to 3 g/day) or diazo-bonded 5-ASA rather than low-dose mesalamine, sulfasalazine, or no treatment is recommended in patients with mild to moderate UC; and
  • Mesalamine suppositories are recommended in patients with mild–moderate ulcerative proctitis who choose rectal therapy over oral therapy.

The guideline also included several “conditional” recommendations. Some of those included:

  • Adding rectal mesalamine to oral 5-ASA in patients with extensive or left-sided mild to moderate UC;
  • Using once-daily dosing rather than multiple times per day dosing in patients with mild to moderate UC being treated with oral mesalamine; and
  • Using mesalamine enemas rather than rectal corticosteroids in patients with mild to moderate ulcerative proctosigmoiditis who choose rectal therapy over oral therapy.

Less-conventional therapies such as probiotics, curcumin and fecal microbiota transplantation were not recommended for the treatment of patients with mild to moderate UC.

“I think to get a stronger recommendation, additional clinical trials will need to be performed,” Cross said. “They are going to be able to increase our confidence that those treatments are effective. For those to have stronger weight in the guidelines, there’s going to have to be well done, well designed randomized controlled clinical trials to assess those therapies.”

The guideline, according to Cross, is intended to reduce practice variation and promote high-quality care.

“As much as possible, we want to try and standardize how we treat patients with mild to moderate colitis,” he said. “Making sure that patients get started on an appropriate dose of a compound. Then, trying to use topical therapies if patients are accepting, doing a reassessment of symptoms within 2 to 4 weeks and then potentially pushing the dose or adding topical therapy for those that aren’t responding is critically important. The goal here is to decrease the suffering of patients with ulcerative colitis and by trying to optimize therapy and standardize treatments, we can determine quickly if that is the right therapy for a patient or whether they need to escalate to something else. Particularly for mild to moderate ulcerative colitis, which in general is fairly homogeneous and can be standardized, how we treat it initially, we can try to get providers practicing in the same way.” – by Ryan McDonald

Disclosure: Cross reports no relevant financial disclosures.

Raymond Cross, MD
Raymond K. Cross

The American Gastroenterological Association has released new clinical guidelines on the management of patients with mild to moderate ulcerative colitis, focusing on the use of both oral and topical 5-aminosalicylates, rectal corticosteroids and oral budesonide.

“Mild to moderate ulcerative colitis really [constitutes] the largest group of patients that we see with that disorder,” Raymond K. Cross, MD, MS, director of the Inflammatory Bowel Disease Program at University of Maryland School of Medicine, and guideline co-author, told Healio Gastroenterology and Liver Disease. “These are patients that are primarily treated with 5-aminosalicylates, and that’s the vast majority of what is seen in the community.”

Developed by the AGA Institute’s Clinical Guidelines Committee, the guidelines are accompanied by a technical review that includes a compilation of the evidence on which the recommendations were formulated.

The guideline included two “strong” recommendations that were supported by a “moderate” amount of quality evidence:

  • Standard-dose mesalamine (2 to 3 g/day) or diazo-bonded 5-ASA rather than low-dose mesalamine, sulfasalazine, or no treatment is recommended in patients with mild to moderate UC; and
  • Mesalamine suppositories are recommended in patients with mild–moderate ulcerative proctitis who choose rectal therapy over oral therapy.

The guideline also included several “conditional” recommendations. Some of those included:

  • Adding rectal mesalamine to oral 5-ASA in patients with extensive or left-sided mild to moderate UC;
  • Using once-daily dosing rather than multiple times per day dosing in patients with mild to moderate UC being treated with oral mesalamine; and
  • Using mesalamine enemas rather than rectal corticosteroids in patients with mild to moderate ulcerative proctosigmoiditis who choose rectal therapy over oral therapy.

Less-conventional therapies such as probiotics, curcumin and fecal microbiota transplantation were not recommended for the treatment of patients with mild to moderate UC.

“I think to get a stronger recommendation, additional clinical trials will need to be performed,” Cross said. “They are going to be able to increase our confidence that those treatments are effective. For those to have stronger weight in the guidelines, there’s going to have to be well done, well designed randomized controlled clinical trials to assess those therapies.”

The guideline, according to Cross, is intended to reduce practice variation and promote high-quality care.

“As much as possible, we want to try and standardize how we treat patients with mild to moderate colitis,” he said. “Making sure that patients get started on an appropriate dose of a compound. Then, trying to use topical therapies if patients are accepting, doing a reassessment of symptoms within 2 to 4 weeks and then potentially pushing the dose or adding topical therapy for those that aren’t responding is critically important. The goal here is to decrease the suffering of patients with ulcerative colitis and by trying to optimize therapy and standardize treatments, we can determine quickly if that is the right therapy for a patient or whether they need to escalate to something else. Particularly for mild to moderate ulcerative colitis, which in general is fairly homogeneous and can be standardized, how we treat it initially, we can try to get providers practicing in the same way.” – by Ryan McDonald

Disclosure: Cross reports no relevant financial disclosures.

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