Q&A with Dr. Nandi: ACG Ulcerative Guidelines

For the first time in 10 years, The American College of Gastroenterology has issued updated clinical guidelines on the management of ulcerative colitis (UC). Its approach has changed from addressing the treatment of inflammatory bowel disease (IBD) symptoms, to add mucosal healing (MH). We asked Dr. Nandi some questions about this change and what it means for patients.

1. Why is this 2019 ACG guideline change significant?

The guidelines have not been updated since 2010. Hence, these new 2019 ACG Ulcerative Colitis Guidelines reflect a much-needed update that reflects all the numerous breakthroughs that have occurred since then. In fact, there were a total of 49 recommendations and 54 summary statements forged after an extensive and systematic review of evidence-based medicine research conducted over the last decade.

Sometimes guidelines can be mired in gray zones without solid recommendations. Fortunately, these guidelines are quite the opposite. They were expressly written to offer your GI physician more practical insight so that UC management was more straightforward. Greater clarity and practical guidelines means better care for our patients!

2. What do you think is most important about this change?

Highlights include the emphasis on mucosal healing. Some UC patients may have active disease but not realize and be asymptomatic. This uncontrolled disease activity can lead to progression of ulcerations, scarring and promote the development from of pre-cancer to colon cancer! I tell my patients that we need to know that they ‘Look as good on the inside as they feel on the outside.’ Then we know they have achieved not just ‘clinical remission’, but "mucosal remission." Thus, the guidelines, place good emphasis on this as a primary goal of any and all therapy.

Also, there is a recommendation to minimize colonoscopy. You read that right, but how? We have been able to establish the use of a non-invasive (no colonoscopy) marker to monitor disease. This marker is known as faecal calprotectin. It is a protein released from white blood cells attacking the intestine. If you have active disease, then faecal calprotectin may be elevated. Elevated faecal calprotectin when asymptomatic can help predict and avoid a flare. A faecal calprotectin that trends downwards to normal can also be consistent with mucosal healing!

The guideline also summarizes and endorses the use of multiple agents that have been developed for ulcerative colitis that did not exist in 2010 including: (Anti-TNF: Golimumab, Anti-Integrin: Vedoluzimab, JAK inhibitor: Tofacitinib.

Notably, treatment with a thiopurine (6-MP or Azathioprine) or methotrexate alone is recommended against in favor of other therapies.

Concrete guidelines were also provided on the management of those patients requiring hospitalization for acute severe ulcerative colitis (ASUC) so that doctors had better guidance on when to switch therapy or management than before. Colon cancer can definitely be prevented in UC and the guidelines highlight a review of more convenient and effective techniques to prevent cancer in our patients.

3. What does this change mean for ulcerative colitis patients?

The lack of guidelines can be wielded by insurance companies to deny coverage for diagnostic testing, colonoscopy and treatments. Thus, the establishment of up-to-date guidelines empowers your physician to appeal their decisions grounded in established evidence-based medicine that has been peer-reviewed nationally by an expert panel of IBD specialists. These solid recommendations should help clinicians help their patients.

4. Can patients expect their treatment to change?

If so, how long will it take for this change to happen?

These treatments exist now in present time. Therefore, there is no delay but having the guidelines may afford your IBD care team the ACG backing to appeal for medications or diagnostics that can help improve your care. See question 6 on what you can do to inquire whether a treatment change may be indicated for you – or not.

5. Changes in clinical trials?

Since this might be used as another endpoint for clinical trials, are there drugs/drug classes that you think will incorporate this in trials soon?

Mucosal healing has already been incorporated as a primary endpoint in clinical trials for at least 5 years. Thus, all active trials and those still ongoing are measuring mucosal healing as one of several standards to achieve when defining true efficacy. This is great news for our patients especially in understanding the efficacy of these existing and emerging treatment options.

6. What is a good next step for ulcerative colitis patients to take?

Review your last colonoscopy and ask your doctor if you have achieved mucosal healing. Ask them if they believe a faecal calprotectin may be a test that can be checked periodically to ensure good healing between your colonoscopic exams.

If you have any symptoms not adequately controlled, ask your doctor if this may be active UC. If so, you may consider one of these other therapeutic options endorsed in the guideline.

7. What are some questions that patients can ask their doctors about this?

• Do I have mucosal healing?
• Can we check a faecal calprotectin prior to my next colonoscopy?
• Can we trend calprotectins going forth after correlating to next scope?
• Is there a role for checking drug and antibody levels of my specific therapy to better optimize my mucosal healing? (Therapeutic Drug Monitoring)
• If I am not responding to my present therapy, are these other therapies appropriate for me?