Ulcerative Colitis Clinical Practice Guidelines (2019)

American College of Gastroenterology

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

March 22, 2019

The American College of Gastroenterology (ACG) published recommendations on ulcerative colitis (UC) in adults in March 2019.[1,2] The focus of management has shifted from symptom-based treatment to symptom management and mucosal healing.

Diagnosis, Assessment, and Prognosis

Stool testing is recommended to exclude Clostridioides difficile when UC is suspected.

Serologic antibody testing is not recommended for the following:

  • To establish or exclude a diagnosis of UC

  • To determine the prognosis of UC

Goals for Managing Patients With UC

Treat patients with UC to achieve mucosal healing (ie, resolution of inflammatory changes [Mayo endoscopic subscore 0 or 1]) to increase the likelihood of sustained steroid-free remission and prevent hospitalizations and surgery.

UC Management

Induction and maintenance of remission in mildly active UC

Patients with, or who previously had, mildly active ulcerative proctitis are recommended to receive rectal (PR) 5-aminosalicylate (5-ASA) therapies at a dose of 1 g/d to induce or maintain remission.

To induce remission in patients with mildly active left-sided UC:

  • Rectal 5-ASA enemas at a dose of at least 1 g/d are preferred over rectal steroids.

  • In the setting of intolerance or nonresponse to oral (PO) and PR 5-ASA at appropriate doses (PO: ≥2 g/d; PR: ≥1 g/d), use PO budesonide multi-matrix (MMX) 9 mg/d.

Patients with mildly active extensive UC are recommended to receive PO 5-ASA at a dose of at least 2 g/d to induce remission.

Patients with UC of any extent whose condition fails to respond to 5-ASA therapy are recommended to receive PO systemic corticosteroids to induce remission.

Patients with mildly to moderately active UC refractory to PO 5-ASA are recommended to additionally receive budesonide MMX 9 mg/d to induce remission.

Patients with mildly to moderately active UC of any extent using 5-ASA to induce remission are recommend to receive either once-daily or more frequently dosed PO 5-ASA based on patient preference to optimize adherence, as efficacy and safety are no different.

Patients with mildly active left-sided or extensive UC are recommend to receive at least 2 g/d of PO 5-ASA therapy for maintenance of remission.

Systemic corticosteroids are not recommended to maintain remission in patients with UC.

Management of Moderately to Severely Active UC

Induction of remission

For moderately active UC, PO budesonide MMX is recommended to induce remission.

For moderately to severely active UC of any extent, PO systemic corticosteroids are recommended to induce remission.

To induce remission in patients with moderately to severely active UC, note the following:

  • Monotherapy with thiopurines or methotrexate is not recommended.

  • Anti-tumor necrosis factor (TNF) therapy using adalimumab, golimumab, or infliximab is recommended.

  • When infliximab is used as induction therapy, combination therapy with a thiopurine is recommended.

  • Vedolizumab or tofacitinib (tofacitinib: 10 mg PO twice daily × 8 wk) is recommended (either agent is also recommended when anti-TNF therapy has failed previously).

Maintenance of remission in those with previously moderately to severely active UC

Systemic corticosteroids are not recommended to maintain remission in patients with UC.

Continue anti-TNF therapy using adalimumab, golimumab, or infliximab to maintain remission after anti-TNF induction in patients with previously moderately to severely active UC.

Continue vedolizumab to maintain remission in patients with previously moderately to severely active UC now in remission after vedolizumab induction.

Continue tofacitinib to maintain remission in patients with previously moderately to severely active UC now in remission after tofacitinib induction.

Management of Hospitalized Patients With Acute Severe UC (ASUC)

Apply deep venous thrombosis (DVT) prophylaxis to prevent venous thromboembolism (VTE).

Test for C difficile infection (CDI).

In the setting of ASUC and concomitant CDI, treat CDI with vancomycin instead of metronidazole.

Routine use of broad-spectrum antibiotics is not recommended to manage ASUC.

Use methylprednisolone 60 mg/d or hydrocortisone 100 mg 3 or 4 times daily to induce remission.

In the setting of ASUC with inadequate response to intravenous corticosteroids (IVCS) by 3-5 days, medical rescue therapy with infliximab or cyclosporine is recommended.

When remission is achieved with infliximab treatment, maintain remission with infliximab.

Colorectal Cancer Prevention in UC

When using standard-definition colonoscopes in those with UC undergoing surveillance, dye spray chromoendoscopy with methylene blue or indigo carmine is recommended to identify dysplasia.

For more information, please go to Ulcerative Colitis.

For more Clinical Practice Guidelines, please go to Guidelines.

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