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ACG issues practice guidelines for management of ulcerative colitis

Wednesday, March 10 2010 | Comments

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What's This? The American College of Gastroenterology (ACG) issued new guidelines to aid in the diagnosis and management of ulcerative colitis (UC) in adults.

Each recommendation was graded based on the level of evidence available to support it, with possible grades ranging from A (based on Level 1 evidence from randomized, controlled trials) to D (Level 5 evidence consisting of expert opinion).

For the management of mild to moderate distal colitis, the ACG recommended the use of oral aminosalicylates, topical mesalamine, or topical steroids (Grade A), adding that topical mesalamine is superior to the other 2 regimens (Grade A) and that the combination of oral and topical aminosalicylates is more effective than either approach alone (Grade A). In refractory cases or in patients who are systemically ill, the group noted that oral prednisone or infliximab may be necessary but have not been studied specifically in patients with distal disease (Grade C).

For the maintenance of remission in distal disease, the ACG recommended the use of mesalamine suppositories in patients with proctitis and mesalamine enemas in patients with distal colitis (Grade A), adding that sulfasalazine, mesalamine compounds, and balsalazide disodium are also effective and that the combination of oral and topical mesalamine is more effective than either therapy alone (Grade A). If these agents should fail to maintain remission, other treatment options include thiopurines and infliximab (Grade A).

For the management of mild to moderate extensive colitis, the ACG recommended initial treatment with oral sulfasalazine or another aminosalicylate (Grade A), reserving oral steroids for patients who do not respond to a combination of oral aminosalicylates and topical therapy or for patients with symptoms requiring rapid improvement (Grade B). For patients who do not respond to steroids or are steroid-dependent, even with the addition of a thiopurine, and for patients who cannot tolerate these agents, infliximab may be effective, provided there are no contraindications (Grade A).

To maintain remission in these patients, the ACG recommended the use of sulfasalazine, olsalazine sodium, mesalamine, or balsalazide (Grade A) but cautioned against chronic treatment with steroids. The group added that the thiopurines azathioprine and 6-mercaptopurine may be useful in steroid-dependent patients and in cases when remission cannot be maintained with aminosalicylates (Grade A). In patients who responded to an infliximab induction regimen, infliximab is effective for maintaining remission (Grade A).

For patients with severe colitis who have not responded to other medications, the ACG recommended infliximab (Grade A). However, the group noted, patients presenting with toxicity should be hospitalized to receive intravenous (IV) steroids (Grade C); infliximab may be effective in patients who do not respond to IV steroids (Grade A). If severe colitis does not improve within 3 to 5 days, intravenous cyclosporine (Grade A) or colectomy (Grade B) may be indicated.

Surgery is indicated for patients with exsanguinating hemorrhage, perforation, or documented or strongly suspected carcinoma (Grade C), as well as for patients with severe colitis with or without toxic megacolon that is unresponsive to medical therapy and for patients with less severe but treatment-resistant symptoms or an inability to tolerate drug therapy.

Lastly, the ACG made recommendations for cancer surveillance in patients with UC, suggesting that surveillance colonoscopies and biopsies are warranted in patients with disease duration of 8 to 10 years (Grade B). Colectomy is indicated in the presence of high-grade dysplasia in flat mucosa, if the findings are confirmed by an expert pathologist; low-grade dysplasia may also be an indication for colectomy to prevent neoplasia progression (Grade B). (Kornbluth A, et al. Am J Gastroenterol 2010;105:501-523.)

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