New Guideline on Management of Mild-to-Moderate Ulcerative Colitis

IBD

Kenneth R. McQuaid, MD, FASGE reviewing Ko CW, et al. Gastroenterology 2018 Dec 18.

Must-read new guideline on mild-to-moderate UC. The highlights of the 12 recommendations are distilled below. The authors used the GRADE framework. They identify a knowledge gap regarding fecal microbiota transplantation (FMT) and curcumin use.

Background and Definitions

Mild-to-moderate UC is <4-6 bowel movements/day, mild-moderate bleeding, and absence of constitutional symptoms or features suggesting significant inflammation.
Disease location: extensive disease: extending proximal to splenic flexure; left-sided: up to splenic flexure; proctitis: <20 cm.
Oral mesalamine (5-ASA) or diazo-bonded 5-ASA (balsalazide) given orally and/or topical 5-ASA (enema, suppository) remain mainstays of initial therapy. Sulfasalazine is no longer recommended unless prominent arthritic symptoms.
Oral mesalamine formulations are deemed equally effective at equivalent doses. All oral 5-ASA products may be given once daily.
Standard dosing is mesalamine 2-3 g/d or balsalazide 6.75 g/d; low-dose mesalamine (<2 g/d) is sometimes used for maintenance but is less effective than standard dosing. Role of high-dose mesalamine (>3-4.8 g/d) is defined below.
Due to low risk of interstitial nephritis, renal function (creatinine, urinalysis) is recommended “periodically.”

Recommendations

Extensive or left-sided disease: a combination of standard-dose oral mesalamine or balsalazide andrectal 5-ASA is recommended, with high dose recommended for moderate activity or suboptimal response to standard dose.
Proctitis or proctosigmoiditis: topical 5-ASA recommended rather than oral mesalamine unless patient preference. Mesalamine enemas are superior to steroid enemas. For proctitis, suppositories (1-1.5 g/d) are preferred. Rectal corticosteroid therapy (budesonide or hydrocortisone foam or enema) suggested for refractory proctitis.
For mild-to-moderate UC refractory to oral and rectal 5-ASA, systemic corticosteroid therapy (prednisone or budesonide MMX) should be considered. Second-generation steroids (CIR-budesonide, beclomethasone, and fluticasone) have similar efficacy for induction of remission with fewer adverse events but higher costs.
Patients unresponsive to these therapies or who worsen may require systemic steroids, immunomodulators, or biologics.

Comment:

These recommendations consider quality of current evidence, balancing harms and benefit of treatments, and patient preferences.

Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.

Kenneth R. McQuaid, MD, FASGE

Bio and Disclosures

Citation(s):

Ko CW, Singh S, Feuerstein JD, et al. American Gastroenterological Association Institute guideline on the management of mild-to-moderate ulcerative colitis. Gastroenterology 2018 Dec 18. (Epub ahead of print) (https://doi.org/10.1053/j.gastro.2018.12.009)