Inflammatory Bowel Disease Clinical Practice Guidelines (2019)

British Society 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.

November 04, 2019

Consensus guidelines on the management of inflammatory bowel disease in adults were released in September 2019 by the British Society of Gastroenterology.[1]

Ulcerative Colitis

In circumstances in which ulcerative colitis is diagnosed by sigmoidoscopy, the recommended procedure is a full ileocolonoscopy to delineate the extent of disease and the severity of inflammation, as well as to exclude Crohn disease.

The target of medical therapy for ulcerative colitis is symptomatic remission combined with mucosal healing.

For the initial treatment of active mild-to-moderate ulcerative colitis with 5-aminosalicylic acid (5-ASA), oral 5-ASA at 2-3 g/day is recommended; 5-ASA enemas are also recommended, rather than oral treatment alone. All patients treated with 5-ASA should undergo monitoring for nephrotoxicity, with baseline renal function testing repeated after 2-3 months, and then annually thereafter.

For corticosteroid treatment in mild-to-moderate ulcerative colitis in patients in whom 5-ASA therapy has failed or is not tolerated, oral prednisolone is recommended. Also recommended is topically acting oral corticosteroids (eg, budesonide MMX).

For corticosteroid treatment in moderate-to-severe ulcerative colitis, oral corticosteroids (eg, prednisolone at 40 mg/d with weaning over 6-8 wk) is recommended.

5-ASA is recommended as standard maintenance medical therapy. Considerations for the choice of formulation include patient preference, likelihood of adherence, and cost. Once-daily dosing is considered effective and may help improve adherence.

In cases of 5-ASA treatment failure, options to consider include thiopurine, anti–tumor necrosis factor therapy, vedolizumab, or tofacitinib. Considerations for choice of drug include clinical factors, patient choice, cost, likelihood of adherence, and local infusion capacity.

Regarding surgical management for ulcerative colitis, it is generally suggested that surgical resection of the colon and rectum should be offered to those patients with chronic active symptoms that are refractory to optimal medical therapy.

Proctitis in ulcerative colitis

The recommended treatment for mild or moderately active ulcerative proctitis is a 1-g 5-ASA suppository.

If patients do not respond to or are intolerant of 5-ASA suppositories and oral 5-ASA, they can be switched to corticosteroid suppositories.

In refractory proctitis, it is suggested that patients may require treatment with corticosteroids, immunomodulators, and/or biological therapy.

Acute severe ulcerative colitis

The recommended treatment for acute severe ulcerative colitis is high-dose intravenous corticosteroids (eg, methylprednisolone at 60 mg/day or hydrocortisone at 100 mg q6h), along with prophylactic low-molecular-weight heparin. Do not delay corticosteroid treatment for patients with suspected acute severe ulcerative colitis pending results of stool cultures and Clostridium difficile assay.

If patients do not respond by day 3, rescue therapy with intravenous infliximab or cyclosporine should be offered for patients in whom previous thiopurine therapy has failed. If patients treated with infliximab have not responded sufficiently to a 5-mg/kg dose 3-5 days after the first infusion, offer an accelerated induction regimen after a colorectal surgical consult to determine if an emergency colectomy is required.

In patients with acute severe ulcerative colitis who do not respond to rescue therapy with infliximab or cyclosporine within 7 days, or in those who deteriorate or experience complications (including severe hemorrhage, perforation, or toxic megacolon) before 7 days, subtotal colectomy and ileostomy, with preservation of the rectum, are required. Note that a delay in surgery increases the risk of surgical complications; therefore, early referral and direct involvement with specialist colorectal surgical and stoma care teams is required.

Pouches and pouchitis

The recommend first-line treatment for acute pouchitis is a 2-week course of ciprofloxacin or metronidazole. Ciprofloxacin may be better tolerated and more effective than metronidazole.

The suggested treatment for chronic pouchitis is combination antibiotic therapy (ciprofloxacin, metronidazole, tinidazole, rifaximin), oral budesonide, or oral beclomethasone.

In chronic refractory pouchitis that does not respond to antibiotics or locally acting corticosteroids, reassess the patient and consider other factors. If other factors can be excluded, the suggested next step is to offer patients biologics.

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