AGA Releases New Guidelines on Management of Ulcerative Colitis

The American Gastroenterological Association (AGA) recently released new guidelines on the management of moderate-to-severe ulcerative colitis (UC) in adult outpatients.¹

UC, a chronic inflammatory bowel disease, often emerges in early adulthood. Conventional therapies for the long-term management of UC can include tumor necrosis factor-alpha antagonists, anti-integrin agent, janus kinase inhibitor, and immunomodulators.

According to the AGA’s guideline, which was published in Gastroenterology, the recommendations focus on immunomodulators, biologics, and small molecules for induction and maintenance of remission and decreasing the risk of colectomy.¹

Of the 15 recommendations discussed in the guideline, the AGA noted that the following 5 are the most noteworthy:²

• In adult outpatients with moderate-to-severe UC, AGA recommends using infliximab, adalimumab, golimumab, vedolizumab, tofacitinib, or ustekinumab over no treatment. (Strong recommendation: moderate quality evidence)

• In adult outpatients with moderate-to-severe UC who are new to biologics, AGA suggests using infliximab or vedolizumab rather than adalimumab for induction of remission. (Conditional recommendation: moderate quality evidence)

Comment: Patients, particularly those with less severe disease, who place higher value on the convenience of self-administered subcutaneous injection, and a lower value on the relative efficacy of medications, may reasonably choose adalimumab as an alternative.

• In adult outpatients with moderate-to-severe UC who have been exposed to infliximab, particularly those who are not responsive, AGA suggests using ustekinumab or tofacitinib, rather than vedolizumab or adalimumab, for induction of remission. (Conditional recommendation: low quality evidence)

Comment: Patients, particularly those with less severe disease who place higher value on the potential safety of medications, and a lower value on the relative efficacy of medications, may reasonably choose vedolizumab as an alternative.

• In adult outpatients with moderate-to-severe UC, AGA suggests early use of biologics with or without immunomodulator therapy, rather than gradual step up after failure of 5-aminosalicylates. (Conditional recommendation: very low quality evidence)

Comment: Patients, particularly those with less severe disease, who place higher value on the safety of 5-ASA therapy, and lower value on the efficacy of biologic agents, may reasonably choose gradual step therapy with 5-ASA therapy.

• In hospitalized adult patients with acute severe UC refractory to intravenous corticosteroids, AGA suggests using infliximab or cyclosporine. (Conditional recommendation: low quality evidence)

Looking ahead, the guideline authors highlighted areas for future research in patients with moderate-to-severe UC.

“With an increasing number of different drug classes available to treat UC, there is a clear need for identifying biomarkers predictive of response to individual therapies, to facilitate optimal positioning of therapies,” they wrote.¹

Moreover, future head-to-head trials can directly inform comparative efficacy and strengthen the quality of evidence from network meta-analyses, according to the authors.¹

The authors also suggested that more insight into the utility and duration of combination therapy of biologics and immunomodulators in patients with UC is needed, as well.¹

References:

• Feuerstein JD, Isaacs KL, Schneider Y, et al. AGA clinical practice guidelines on the management of moderate to severe ulcerative colitis. Gastroenterology. 2020. Doi: https://doi.org/10.1053/j.gastro.2020.01.006.

• New AGA guideline: management of ulcerative colitis [news release]. American Gastroenterological Association’s website. https://www.gastro.org/news/new-aga-guideline-management-of-ulcerative-colitis. Accessed January 23, 2020.