Patients with extensive mild to moderate ulcerative colitis should receive standard-dose mesalamine (2 to 3 g/d) or diazo-bonded 5-aminosalicylic acid (5-ASA) medications rather than low-dose mesalamine, sulfasalazine, or no treatment, according to guideline recommendations issued by the American Gastroenterological Association Institute.
Use of combined oral and rectal 5-ASA in patients with extensive disease may improve remission rates, as may escalation to high-dose oral 5-ASA in combination with rectal 5-ASA in patients with suboptimal response to standard-dose therapy, the guideline said.
The guideline addresses medical management of patients with mild to moderate ulcerative colitis, focusing on oral and topical 5-ASA medications, rectal corticosteroids, and oral budesonide. It covers appropriate therapy for patients with extensive disease, with additional specific recommendations for patients with proctosigmoiditis or isolated proctitis. It does not address nonresponders who need to escalate therapy to systemic corticosteroids, immunomodulators, and biologic therapies to achieve remission.
The guideline was published early online Dec. 18 by Gastroenterology.
Mild to moderate ulcerative colitis was defined as fewer than four to six bowel movements per day, mild to moderate rectal bleeding, absence of constitutional symptoms, low overall inflammatory burden, and absence of features suggesting high inflammatory activity. Patients with more frequent bowel movements, more prominent rectal bleeding, or greater overall inflammatory burden should be considered to have moderate disease, the guideline said.
Age younger than 40 years at diagnosis, extensive disease, severe endoscopic activity such as deep ulcers, extra-intestinal manifestations, and elevated inflammatory markers may predict an aggressive disease course, even in patients with mild to moderate disease, the guideline stated. Clinicians should use these features to identify patients who may benefit from more aggressive initial therapy or who might need more rapid intensification of therapy if symptoms are not adequately controlled.
Clinicians should avoid repeated courses of corticosteroids and should consider escalation of therapy in patients who frequently need corticosteroids for disease control, the guideline said. The guideline defined extensive disease as inflammation extending proximal to the splenic flexure, left-sided disease as inflammation extending proximal to the rectum but not past the splenic flexure (or <50 cm from the anus), and proctitis as inflammation limited to the rectum (or <15 to 20 cm from the anus). Both disease severity and anatomic extent are important in choosing appropriate treatment, the guideline stated.
The 13 recommendations include the following:
- Patients with extensive or left-sided mild to moderate ulcerative colitis can add rectal mesalamine to oral 5-ASA (conditional recommendation, moderate-quality evidence).
- Patients with mild to moderate ulcerative colitis with suboptimal response to standard-dose mesalamine or diazo-bonded 5-ASA or with moderate disease activity can use high-dose mesalamine (>3 g/d) with rectal mesalamine (conditional recommendation, moderate-quality evidence for induction of remission, low-quality evidence for maintenance of remission).
- Patients using oral mesalamine should use once-daily dosing rather than dosing multiple times per day (conditional recommendation, moderate-quality evidence).
- Patients with mild to moderate ulcerative colitis should use standard-dose oral mesalamine or diazo-bonded 5-ASA, rather than budesonide MMX or controlled ileal-release budesonide to achieve remission (conditional recommendation, low-quality evidence).