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    Ulcerative Colitis in Adults (beta)

    Official guideline from the American College of Gastroenterology.

    Strength
    Strong recommendation
    Conditional recommendation
    Evidence
    High quality evidence
    Moderate quality evidence
    Moderate for azathioprine
    Low quality evidence
    Very low quality evidence

    Diagnosis, Assessment, and Prognosis of Ulcerative Colitis

    Diagnosis, Assessment, and Prognosis of Ulcerative Colitis
    1. We recommend stool testing to rule out Clostridioides difficile in patients suspected of having UC.
    2. We recommend against serologic antibody testing to establish or rule out a diagnosis of UC.
    3. We recommend against serologic antibody testing to determine the prognosis of UC.

    Goals for Managing Patients with Ulcerative Colitis

    Goals for Managing Patients with Ulcerative Colitis
    1. We suggest treating patients with UC to achieve mucosal healing (defined as resolution of inflammatory changes (Mayo endoscopic subscore 0 or 1)) to increase the likelihood of sustained steroid-free remission and prevent hospitalizations and surgery.
    2. We suggest FC as a surrogate for endoscopy when endoscopy is not feasible or available to assess for mucosal healing.

    Induction of Remission

    Mildly Active Ulcerative Colitis
    1. In patients with mildly active ulcerative proctitis, we recommend rectal 5-ASA therapies at a dose of 1 g/d for induction of remission.
    2. In patients with mildly active left-sided colitis, we recommend rectal 5-ASA enemas at a dose of at least 1 g/d preferred over rectal steroids for induction of remission.
    3. In patients with mildly active left-sided UC, we suggest rectal 5-ASA enemas at a dose of at least 1 g/d combined with oral 5-ASA at a dose of at least 2 g/d compared with oral 5-ASA therapy alone for induction of remission.
    4. In patients with mildly active left-sided UC who are intolerant or nonresponsive to oral and rectal 5-ASA at appropriate doses (oral at least 2 g/d and rectal at least 1 g/d), we recommend oral budesonide MMX 9 mg/d for induction of remission.
    5. In patients with mildly active extensive colitis, oral 5-ASA at a dose of at least 2 g/d is recommended to induce remission.
    6. In patients with UC of any extent who fail to respond to 5-ASA therapy, we recommend oral systemic corticosteroids to induce remission.
    7. In patients with mildly active UC who fail to reach remission with appropriately dosed 5-ASA (at least 2 g/d oral 5-ASA and/or at least 1 g/d rectal 5-ASA), we suggest against changing to an alternate 5-ASA formulation to induce remission. Alternative therapeutic classes should be considered.
    8. In patients with mildly active UC of any extent, we suggest using a low dose (2–2.4 g/d) of 5-ASA compared with a higher dose (4.8 g/d), as there is no difference in the remission rate.
    9. In patients with mildly to moderately active UC not responding to oral 5-ASA, we recommend the addition of budesonide MMX 9 mg/d to induce remission.
    10. In patients with mildly to moderately active UC of any extent using 5-ASA to induce remission, we recommend either once-daily or more frequently dosed oral 5-ASA based on patient preference to optimize adherence, as efficacy and safety are no different.
    Moderately to Severely Active Ulcerative Colitis
    1. In patients with moderately active UC, we recommend oral budesonide MMX for induction of remission.
    2. In patients with moderately to severely active UC of any extent, we recommend oral systemic corticosteroids to induce remission.
    3. In patients with moderately to severely active UC, we recommend against monotherapy with thiopurines or methotrexate for induction of remission.
    4. In patients with moderately to severely active UC, we recommend anti-TNF therapy using adalimumab, golimumab, or infliximab for induction of remission.
    5. In patients with moderately to severely active UC who have failed 5-ASA therapy and in whom anti-TNF therapy is used for induction of remission, we suggest against using 5-ASA for added clinical efficacy.
    6. When infliximab is used as induction therapy for patients with moderately to severely active UC, we recommend combination therapy with a thiopurine.
    7. In patients with moderately to severely active UC, we recommend vedolizumab for induction of remission.
    8. In patients with moderately to severely active UC who have previously failed anti-TNF therapy, we recommend vedolizumab for induction of remission.
    9. In patients with moderately to severely active UC, we recommend tofacitinib 10 mg orally b.i.d. for 8 weeks to induce remission.
    10. In patients with moderately to severely active UC who have previously failed anti-TNF therapy, we recommend tofacitinib for induction of remission.
    11. In patients with moderately to severely active UC who are responders to anti-TNF therapy and now losing response, we suggest measuring serum drug levels and antibodies (if there is not a therapeutic level) to assess the reason for loss of response.

    Maintenance of Remission

    Previously Mildly Active Ulcerative Colitis
    1. In patients with mildly active ulcerative proctitis, we recommend rectal 5-ASA at a dose of 1 g/d to maintain remission.
    2. In patients with mildly active left-sided or extensive UC, we recommend oral 5-ASA therapy (at least 2 g/d) for maintenance of remission.
    3. We recommend against systemic corticosteroids for maintenance of remission in patients with UC.
    Previously Moderately to Severely Active Ulcerative Colitis
    1. In patients with previously moderately to severely active UC who have achieved remission but previously failed 5-ASA therapy and are now on anti-TNF therapy, we recommend against using concomitant 5-ASA for efficacy of maintenance of remission.
    2. We recommend against systemic corticosteroids for maintenance of remission in patients with UC.
    3. For patients with previously moderately to severely active UC now in remission due to corticosteroid induction, we suggest thiopurines for maintenance of remission compared with no treatment or corticosteroids.
    4. In patients with previously moderately to severely active UC now in remission, we recommend against using methotrexate for maintenance of remission.
    5. We recommend continuing anti-TNF therapy using adalimumab, golimumab, or infliximab to maintain remission after anti-TNF induction in patients with previously moderately to severely active UC.
    6. We recommend continuing vedolizumab to maintain remission in patients with previously moderately to severely active UC now in remission after vedolizumab induction.
    7. We recommend continuing tofacitinib for maintenance of remission in patients with previously moderately to severely active UC now in remission after induction with tofacitinib.

    Management of the Hospitalized Patient with Acute Severe Ulcerative Colitis

    Management of the Hospitalized Patient with Acute Severe Ulcerative Colitis
    1. In patients with ASUC, we recommend DVT prophylaxis to prevent VTE.
    2. In patients with ASUC, we recommend testing for CDI.
    3. In patients with ASUC and concomitant CDI, we recommend treatment of CDI with vancomycin instead of metronidazole.
    4. We recommend against the routine use of broad-spectrum antibiotics in the management of ASUC.
    5. We suggest against total parenteral nutrition for the purpose of bowel rest in ASUC.
    6. In patients with ASUC, we recommend a total of 60 mg/d of methylprednisolone or hydrocortisone 100 mg 3 or 4 times per day to induce remission.
    7. In patients with ASUC failing to adequately respond to intravenous corticosteroids by 3–5 days we recommend medical rescue therapy with infliximab or cyclosporine.
    8. In patients with ASUC who achieve remission with infliximab treatment, we recommend maintenance of remission with the same agent.
    9. In patients with ASUC who achieve remission with cyclosporine treatment, we suggest maintenance of remission with thiopurines.
    10. In patients with ASUC who achieve remission with cyclosporine treatment, we suggest maintenance of remission with vedolizumab.

    Colorectal Cancer Prevention in Ulcerative Colitis

    Colorectal Cancer Prevention in Ulcerative Colitis
    1. We suggest colonoscopic screening and surveillance to identify neoplasia in patients with UC of any extent beyond the rectum.
    2. When using standard-definition colonoscopes in patients with UC undergoing surveillance, we recommend dye spray chromoendoscopy with methylene blue or indigo carmine to identify dysplasia.
    3. When using high-definition colonoscopes in patients with UC undergoing surveillance, we suggest white-light endoscopy with narrow-band imaging or dye spray chromoendoscopy with methylene blue or indigo carmine to identify dysplasia.
    What do the icons mean?  
    Research PaperRubin DT, Ananthakrishnan AN, Siegel CA, Sauer BG, Long MD. Acg clinical guideline: ulcerative colitis in adults. Am J Gastroenterol. 2019;114(3):384-413.