With changes in available medications and treatment paradigms, and a need to provide guidance on definitions of disease severity, the American College of Gastroenterology recently updated clinical guidance on the management of adults with ulcerative colitis (UC). Published in The American Journal of Gastroenterology, the update covers nearly a decade and includes changes in monitoring treatment response and recommendations covering all areas of UC management, such as outpatient dysplasia surveillance.
Millie D. Long, MD, MPH, co-author of the guideline update, emphasizes that the guideline is as comprehensive as possible. “We attempted to address as many aspects of UC management as we could, from the use of oral and/or topical mesalamine therapies, to biologic therapies, to small molecule therapies, to dysplasia surveillance, and even the management of the hospitalized UC patient,” she explains. “We tried to make the guideline as PRACTICAL as possible, allowing a gastroenterologist to use these recommendations in his or her practice immediately.”
Dr. Long notes a lack of randomized controlled trials (RCTs) focused on comparative effectiveness of medications, with studies mostly comparing medications with placebo. “This makes it difficult to make recommendations surrounding positioning of medications,” she adds. “However, the large RCT UC Success demonstrated that infliximab combined with azathioprine was superior to either medication alone. In the future, we hope to see more comparative effectiveness studies that will help us surrounding questions of positioning therapies.”
It is with this setting that the document offers a number of important recommendations surround the treatment of UC (Table). “Perhaps one of the most important aspects of the guideline is that we provide suggested criteria (including clinical symptoms, severity of inflammation, and factors surrounding disease prognosis) that will help the practicing gastroenterologist to better define subgroups of disease severity.” Says Dr. Long. “I hope that physicians will take home the importance of monitoring patients after initiation or change of treatment, to ensure that the patient is clinically improved and also has improvement of inflammation. I also hope that providers will consider newer recommendations surrounding dysplasia surveillance in long-standing UC that incorporate either chromoendoscopy or high-definition white light colonoscopy with narrow band imaging as options for surveillance.”