What are the treatment guidelines for Ulcerative Colitis (UC)?

From the Guidelines

For patients with extensive mild-to-moderate ulcerative colitis, the AGA recommends using either standard dose mesalamine (2–3 grams/d) or diazo-bonded 5-ASA rather than low dose mesalamine, sulfasalazine or no treatment. This recommendation is based on the strongest and most recent evidence from the AGA clinical practice guidelines on the management of mild-to-moderate ulcerative colitis 1. The guidelines suggest that mesalamine is effective in reducing inflammation and inducing remission in patients with mild-to-moderate ulcerative colitis.

Key Recommendations

• For patients with extensive mild-to-moderate ulcerative colitis, standard dose mesalamine (2–3 grams/d) or diazo-bonded 5-ASA is recommended 1.
• For patients with left-sided mild-to-moderate ulcerative proctosigmoiditis or proctitis, mesalamine enemas (or suppositories) are suggested rather than oral mesalamine 1.
• For patients with mild-to-moderate ulcerative proctitis who choose rectal therapy over oral therapy, mesalamine suppositories are recommended 1.
• For patients with mild-to-moderate ulcerative colitis refractory to optimized oral and rectal 5-ASA, adding oral prednisone or budesonide MMX is suggested 1.

Treatment Approach

The treatment approach for colitis depends on the type and severity of the condition. For mild to moderate ulcerative colitis, first-line therapy typically includes 5-aminosalicylates (5-ASAs) such as mesalamine or sulfasalazine. These medications reduce inflammation in the colon and can be administered orally or rectally via suppositories or enemas for distal disease. For moderate to severe cases, corticosteroids like prednisone may be necessary for acute flares, as recommended by the British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults 1.

Additional Considerations

• Patients should avoid NSAIDs and antibiotics unless necessary, as these can exacerbate symptoms.
• Surgery (colectomy) may be considered for patients with severe disease unresponsive to medical therapy or those with complications like toxic megacolon or perforation.
• Regular follow-up with gastroenterologists and colonoscopy surveillance is essential due to the increased risk of colorectal cancer in long-standing colitis.

From the FDA Drug Label

Ulcerative Colitis: • reducing signs and symptoms, inducing and maintaining clinical remission and mucosal healing, and eliminating corticosteroid use in adult patients with moderately to severely active disease who have had an inadequate response to conventional therapy. (1. 3)

Pediatric Ulcerative Colitis: • reducing signs and symptoms and inducing and maintaining clinical remission in pediatric patients with moderately to severely active disease who have had an inadequate response to conventional therapy. (1. 4)

Ulcerative Colitis: • 5 mg/kg at 0,2 and 6 weeks, then every 8 weeks. (2.3)

Pediatric Ulcerative Colitis: • 5 mg/kg at 0,2 and 6 weeks, then every 8 weeks. (2. 4)

The treatment guidelines for Colitis using infliximab (IV) are as follows:

• Adult Ulcerative Colitis: 5 mg/kg at 0,2, and 6 weeks, then every 8 weeks.
• Pediatric Ulcerative Colitis: 5 mg/kg at 0,2, and 6 weeks, then every 8 weeks. The goal of treatment is to reduce signs and symptoms, induce and maintain clinical remission, and eliminate corticosteroid use in patients with moderately to severely active disease who have had an inadequate response to conventional therapy 2.

From the Research

Treatment Guidelines for Colitis

• The primary goal of treatment is to induce and maintain remission using therapy tailored to the individual patient 3.
• Treatment options include:
  • Aminosalicylates, which are effective in mild to moderate disease and are used for induction and maintenance of remission 4, 5, 6.
  • Corticosteroids, which are used to treat acute severe refractory to corticosteroids ulcerative colitis and moderate-to-severe ulcerative colitis that is not responsive to conventional treatment 3, 5.
  • Anti-tumor necrosis factor (TNF) agents, such as infliximab, adalimumab, and golimumab, which are effective in induction and maintenance of remission in patients with extensive ulcerative colitis 3.
  • Immunomodulators, such as azathioprine and 6-mercaptopurine, which are used to maintain remission in patients who are steroid-dependent 5.
• The treatment algorithm for mild and moderate-to-severe ulcerative colitis should be guided by the endoscopic extent of inflammation, disease severity, and prognostic factors of poor outcome 7.
• Complete remission, defined as durable symptomatic and endoscopic remission without corticosteroid therapy, is the desired treatment goal 7.
• Treatment recommendations for different clinical scenarios in moderate-to-severe UC include:
  • Active UC of any extent not responding to aminosalicylates: consider adding corticosteroids or anti-TNF agents 7.
  • Steroid-dependent UC: consider adding immunomodulators or anti-TNF agents 7.
  • Steroid-refractory UC: consider adding anti-TNF agents or other biologics 7.
  • Immunomodulator-refractory UC: consider adding anti-TNF agents or other biologics 7.
  • Acute severe UC: consider hospitalization and intensive intravenous treatment with corticosteroids and/or anti-TNF agents 5, 7.