What are the management options for Ulcerative Colitis (UC)?

From the Guidelines

Ulcerative colitis management should prioritize the use of biologic agents such as infliximab, vedolizumab, or tofacitinib for induction and maintenance of remission in moderate to severe cases, as recommended by the AGA clinical practice guidelines 1. When managing ulcerative colitis, it's essential to consider the severity of the disease and the patient's response to previous treatments.

• For biologic-naïve patients, infliximab and vedolizumab may be preferred as first-line therapy over standard-dose adalimumab or golimumab, according to a network meta-analysis 1.
• In patients with prior exposure to infliximab, particularly those with primary non-response to induction therapy, vedolizumab or tofacitinib may be preferred over adalimumab or golimumab 1.
• Combination therapy of a biologic agent with an immunomodulator is more effective than monotherapy with either agent, although patients may opt for monotherapy due to concerns about side effects 1.
• For hospitalized patients with acute severe ulcerative colitis (ASUC), intravenous methylprednisolone doses of 40–60mg/day or equivalent are the mainstay of therapy, with infliximab or cyclosporine considered for patients refractory to corticosteroids 1.
• Patients in remission with biologic agents and/or immunomodulators or tofacitinib after prior failure of 5-ASA may discontinue 5-aminosalicylates 1. The goal of therapy is to achieve and maintain clinical and endoscopic remission, reducing the risk of colorectal cancer and disease complications.
• Ongoing monitoring for medication side effects, screening for extraintestinal manifestations, ensuring adequate nutrition, and providing vaccinations are crucial aspects of ulcerative colitis management, particularly in patients receiving immunosuppressive therapy 1.

From the FDA Drug Label

1.3 Ulcerative Colitis RENFLEXIS is indicated for reducing signs and symptoms, inducing and maintaining clinical remission and mucosal healing, and eliminating corticosteroid use in adult patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy.

1 INDICATIONS AND USAGE ENTYVIO is indicated in adults for the treatment of: moderately to severely active ulcerative colitis (UC).

1.3 Ulcerative Colitis RENFLEXIS is indicated for reducing signs and symptoms, inducing and maintaining clinical remission and mucosal healing, and eliminating corticosteroid use in adult patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy.

Ulcerative Colitis Management:

• Infliximab (IV) and vedolizumab (IV) are indicated for the treatment of moderately to severely active ulcerative colitis.
• The recommended dose of infliximab is 5 mg/kg given as an intravenous induction regimen at 0,2, and 6 weeks followed by a maintenance regimen of 5 mg/kg every 8 weeks thereafter.
• Key considerations:
  • Infliximab and vedolizumab are used in adult patients who have had an inadequate response to conventional therapy.
  • Close monitoring and regular follow-up visits with a physician are necessary when using these medications 2, 3, 2.

From the Research

Ulcerative Colitis Management

• The goals of management are to induce and maintain clinical remission and to screen for complications of the disease 4.
• Mesalamine is a 5-aminosalicylic acid compound that is the first-line therapy to induce and maintain clinical remission in patients with mild-to-moderate ulcerative colitis 4, 5, 6, 7.
• For patients who are refractory to mesalamine or have more severe disease, steroids, azathioprine/mercaptopurine, cyclosporine, or infliximab may be used to induce and/or maintain remission 4, 5, 8.

Treatment Approaches

• Topical treatment with mesalazine is appropriate initial therapy for distal disease, but if symptoms persist, decisive treatment is usually appreciated by the patient 5.
• Corticosteroids have been the mainstay in Europe for mild to moderate disease, although high-dose aminosalicylates are an alternative for symptoms not interfering with daily activity 5.
• Combined oral and topical 5-aminosalicylates, or high-dose oral mesalazine, may be effective for induction of remission and prevention of relapse 7.

Maintenance of Remission

• Aminosalicylates continue to be first-line therapy for the maintenance of remission, although the choice of 5-aminosalicylate appears to be influenced as much by geography as by theoretical considerations 5.
• Steroids have no place in the maintenance of remission, as they are associated with multiple adverse effects 8.
• Azathioprine may be used for patients after a severe relapse of ulcerative colitis, those with early relapse after steroids, and those needing a second course of steroids within a year 5.