New advice on treating ulcerative colitis seeks to reduce practice variation

Last Updated: 2019-01-01

By Reuters Staff

NEW YORK (Reuters Health) - Patients with extensive mild to moderate ulcerative colitis (UC) should be treated with either standard-dose mesalamine (2-3 g/day) or diazo-bonded 5-aminosalicylates (5-ASA) rather than low-dose mesalamine, sulfasalazine or no treatment, according to new practice recommendations developed by the American Gastroenterological Association (AGA).

This is a strong recommendation based on moderate-quality evidence, the guideline committee says. "Patients already on sulfasalazine in remission or patients with prominent arthritic symptoms may reasonably choose sulfasalazine 2-4g/day if alternatives are cost-prohibitive, albeit with higher rate of intolerance," they advise.

The practice recommendations and companion technical report were published online December 18 in Gastroenterology. They focus specifically on managing patients with mild to moderate UC and are intended to "reduce practice variation and promote high quality, high value care."

Among the other key recommendations:

- In patients with extensive or left-sided UC, rectal mesalamine may be added to oral 5-ASA (conditional recommendation, moderate-quality evidence).

- In patients with suboptimal response to standard-dose mesalamine or diazo-bonded 5-ASA or with moderate disease activity, high-dose mesalamine (>3 g/day) with rectal mesalamine may be considered (conditional recommendation, moderate-quality evidence for induction and low-quality evidence for maintenance).

- In patients on oral mesalamine, once-daily dosing rather than dosing multiple times per day may be considered (conditional recommendation, moderate-quality evidence).

- In patients with mild to moderate UC, the AGA suggests using standard-dose oral mesalamine or diazo-bonded 5-ASA, rather than budesonide MMX or controlled ileal-release budesonide for induction of remission (conditional recommendation, low-quality evidence).

- In patients with mild to moderate ulcerative proctosigmoiditis or proctitis, the AGA suggests using mesalamine enemas (or suppositories) rather than oral mesalamine (conditional recommendation, very-low-quality evidence). "Patients who place a higher value on convenience of oral medication administration and a lower value on effectiveness could reasonably choose oral mesalamine," the committee says.

- In patients with ulcerative proctosigmoiditis who choose rectal therapy over oral therapy, the AGA suggests using mesalamine enemas rather than rectal corticosteroids (conditional recommendation, moderate-quality evidence). "Patients who place a higher value on avoiding difficulties associated with mesalamine enemas and a lower value on effectiveness may reasonably select rectal corticosteroid foam preparations," the committee says.

- In patients with mild-moderate ulcerative proctitis who choose rectal therapy over oral therapy, the AGA recommends using mesalamine suppositories (strong recommendation, moderate-quality evidence).

- In patients with mild-moderate ulcerative proctosigmoiditis or proctitis being treated with rectal therapy who are intolerant of or refractory to mesalamine suppositories, use of rectal corticosteroid therapy rather than no therapy for induction of remission is suggested (conditional recommendation, low-quality evidence).

- In patients with UC refractory to optimized oral and rectal 5-ASA, regardless of disease extent, the AGA suggests adding either oral prednisone or budesonide MMX (conditional recommendation, low-quality evidence).

The committee also identified several knowledge gaps and areas for future research in patients with mild to moderate UC. Due to evidence gaps, they were unable to make recommendations for use of probiotics, curcumin, or fecal microbiota transplant (FMT).

"Although these modalities appear to be safe, their use risks delaying proven effective therapy with the potential for worsening symptoms or complications. Thus, further studies of their efficacy and safety as compared to the therapies recommended here are urgently needed," they conclude.

There is also a need to develop and validate risk stratification tools to identify patients who have mild to moderate symptoms who are at high risk of progression to moderate to severe disease and/or colectomy.

Other needs include a better understanding of optimal dosing regimens, in particular which patients might benefit from initial use of high-dose mesalamine or topical mesalamine; better understanding of the relative effectiveness and side effects of budesonide and systemic corticosteroids in patients who do not respond adequately to 5-ASA; and studies to identify the appropriate patient and timing for escalation to immunomodulators and/or biologics.

The guideline was funded by the AGA Institute. The authors disclosed no conflicts of interest.

SOURCE: https://bit.ly/2BH0gwJ

Gastroenterology 2018.