The widespread availability of new and better treatments for ulcerative colitis (UC) prompted a recent update to the national guidelines used to diagnose and manage the condition. In general, rather than a reactive focus on your current symptoms and treating those, your doctor should now take a proactive approach that controls symptoms and promotes mucosal healing, which is a longer-term indicator that your UC is under control.1
New guidelines from the American College of Gastroenterology (ACG)
Announced in March 2019, the new guidelines from the American College of Gastroenterology (ACG) reflect the rapid growth of additional therapeutic classes of drugs over the last 10 years and a greater understanding of how these drugs work in combination with other treatments. Together, these newer drugs and less invasive testing have made it possible for doctors to stop UC’s progression before its more severe complications crop up.2
As the lead author and UC researcher, David T. Rubin, MD, FACG, from the University of Chicago, Illinois, said, “We are finally getting ahead of the disease instead of always chasing it.”1
The guidelines also distinguish between disease activity, which is how sick the person is at evaluation, and disease severity, which can be indicated by younger age at diagnosis, previous hospitalizations, Clostridium difficile (C diff) infection, or more extensive colitis. Before, disease activity and severity were lumped together.
The new recommendations provide options that fine-tune treatment to include oral, topical, and systemic treatments based on the combination of disease activity and severity.3
What’s new in the guidelines
Here are some details for what the new wide-ranging guidelines may mean in the treatment of your UC:
Steroid-free remission is the goal along with a normal quality of life, and prevention of hospitalization, surgery, and cancer. Before, doctors were primarily focused on treating symptoms as they occurred.
Mucosal healing and the absence of ulcers becomes a key goal of UC management, in order to both reduce flare-ups and lessen the need for more severe treatments such as hospitalizations and surgery. Mucosa is the inner tissue lining of the bowel, which becomes inflamed in UC flares.
Even if you are feeling okay, if your test results show signs that your mucosa are inflamed, your doctor may recommend treatment to prevent symptoms or relapse. Other test results that your doctor will use for objective indicators of your UC disease activity include: C diff results, bleeding rate, bowel normalization, and inflammation.
Repeated use of steroids is now to be judged an indication that mucosal healing is not being achieved.
More stool testing, less scoping, is recommended for routine monitoring of mucosal health. That’s because the new guideline recommends the less invasive, less expensive stool test for calprotectin, rather than sigmoidoscopy or colonoscopy, for assessment and monitoring of mucosal inflammation. This test serves as an indicator of active inflammation, response to therapy, and a predictor of relapse.
Stool testing to first rule out C diff infection is recommended in suspected cases of UC.
The use of serologic antibody panels to establish or exclude UC or determine disease prognosis is strongly discouraged.
For left-sided UC, combination oral and topical drugs are recommended, including 5-ASA [aminosalicylates] in enemas, suppositories, and oral doses. Earlier treatment plans tended to use oral therapies alone.
New recommendations are given for the prescription of UC’s newer medications, including several antitumor necrosis factor agents, the anti-integrin antibody vedolizumab (Entyvio, Takeda), and tofacitinib (Xeljanz, PF Prism CV), and the small-molecule oral inhibitor, janus kinase.1-4
For moderate to severe UC
The guideline recommends new severity-based maintenance therapies for people with moderate to severe UC. These therapies focus on preventing the chances of future complications that impact the quality of life and lead to hospital stays and surgery.
It also calls for a surveillance colonoscopy every one to three years to identify and remove precancerous lesions that are more common for people with UC and who are at greater risk for colon cancer.3
Swift, D. Updated UC Guideline Adds Mucosal Healing to Treatment Goal. Available at: https://www.medscape.com/viewarticle/909801. Accessed 4.2.19.
Rubin, D., Ananthakrishnan, et al. ACG Clinical Guideline: Ulcerative Colitis in Adults. Available at: Am J Gastroenterol. 2019. Accessed 4.2.19.
MD Magazine. ACG Releases New Ulcerative Colitis Guideline. Available at: https://www.mdmag.com/medical-news/acg-releases-new-ulcerative-colitis-guideline. Accessed 4.2.19.