Most patients with ulcerative colitis (UC) have mild to moderate disease characterized by periods of activity or remission, but practice variations exist in disease management. A new clinical guideline from AGA published in Gastroenterology, the official journal of AGA, addresses the medical management of these patients, focusing on use of both oral and topical 5-aminosalicylates (5-ASA) medications, rectal corticosteroids, and oral budesonide, to promote high-quality care.
AGA’s new clinical guideline is meant to help with the management of patients with mild to moderate UC, but not all patients will effectively respond to the outlined therapies. In those cases, there may be a need to escalate treatment to systemic corticosteroids, immunomodulators, and/or biologic therapies for induction and maintenance of remission. However, the use of biologic therapies and/or immunomodulators are not specifically addressed within the guideline.
Mild to moderate UC was defined as patients with fewer than four to six bowel movements per day, mild or moderate rectal bleeding, absence of constitutional symptoms, low overall inflammatory burden, and absence of features suggestive of high inflammatory activity. Although disease activity exists on a spectrum, patients in the mild to moderate category who have more frequent bowel movements, more prominent rectal bleeding, or greater overall inflammatory burden should be considered to have moderate disease.
The guideline recommends the following for the medical management of mild-to-moderate ulcerative colitis:
1. Use either standard-dose mesalamine (2-3 grams/day) or diazo-bonded 5-ASA rather than low-dose mesalamine, sulfasalazine, or no treatment in patients with extensive mild-moderate UC. (Strong recommendation, moderate-quality evidence)
2. In patients with extensive or left-sided mild-moderate UC, add rectal mesalamine to oral 5-ASA. (Conditional recommendation, moderate quality evidence)
3. In patients with mild–moderate UC with suboptimal response to standard-dose mesalamine or diazo-bonded 5-ASA or with moderate disease activity, use high-dose mesalamine (more than 3 grams/day) with rectal mesalamine. (Conditional recommendation, moderate-quality evidence [induction of remission], low-quality evidence [maintenance of remission])
4. In patients with mild–moderate UC being treated with oral mesalamine, use once-daily dosing rather than multiple times per day dosing. (Conditional recommendation, moderate-quality evidence)
5. In patients with mild–moderate UC, use standard-dose oral mesalamine or diazo-bonded 5-ASA, rather than budesonide MMX or controlled ileal-release budesonide for induction of remission. (Conditional recommendation, low quality of evidence)
6. In patients with mild–moderate ulcerative proctosigmoiditis or proctitis, use mesalamine enemas (or suppositories) rather than oral mesalamine. (Conditional recommendation, very-low-quality evidence)
7. In patients with mild–moderate ulcerative proctosigmoiditis who choose rectal therapy over oral therapy, use mesalamine enemas rather than rectal corticosteroids.(Conditional recommendation, moderate-quality evidence)
8. In patients with mild–moderate ulcerative proctitis who choose rectal therapy over oral therapy, use mesalamine suppositories. (Strong recommendation, moderate-quality evidence)
9. In patients with mild–moderate ulcerative proctosigmoiditis or proctitis being treated with rectal therapy who are intolerant of or refractory to mesalamine suppositories, use rectal corticosteroid therapy rather than no therapy for induction of remission. (Conditional recommendation, low-quality evidence)
10. In patients with mild–moderate UC refractory to optimized oral and rectal 5-ASA, regardless of disease extent, add either oral prednisone or budesonide MMX. (Conditional recommendation, low-quality evidence)
11. In patients with mild–moderate UC, AGA makes no recommendation for use of probiotics. (No recommendation, knowledge gap)
12. In patients with mild–moderate UC despite 5-ASA therapy, AGA makes no recommendation for use of curcumin. (No recommendation, knowledge gap)
13. In patients with mild–moderate UC without Clostridium difficile infection, AGA recommends fecal microbiota transplantation be performed only in the context of a clinical trial. (No recommendation for treatment of ulcerative colitis, knowledge gap)
The guideline is accompanied by a technical review that is a compilation of the clinical evidence based on which these recommendations were framed.