Mucosal healing an emerging goal of ulcerative colitis treatment, guideline states

The American College of Gastroenterology updated its clinical guideline on ulcerative colitis in adults. Last updated in 2010, the guideline is intended to present a framework for physicians to care for all patients with the condition throughout their disease course and includes takeaways that can be applied to practice quickly.

“Management of [ulcerative colitis] must involve a prompt and accurate diagnosis, assessment of the patient's risk of poor outcomes, and initiation of effective, safe, and tolerable medical therapies,” said the guideline, which was published Feb. 21 in The American Journal of Gastroenterology. “The optimal goal of management is a sustained and durable period of steroid-free remission, accompanied by appropriate psychosocial support, normal health-related quality of life (QoL), prevention of morbidity including hospitalization and surgery, and prevention of cancer.”

For diagnosis and assessment, the guideline recommends in favor of stool testing to rule out Clostridioides difficile (formerly Clostridium difficile) in patients with suspected ulcerative colitis but against serologic antibody testing to establish or rule out a diagnosis or determine the prognosis (all strong recommendations, very low-quality evidence).

An emerging goal in ulcerative colitis management is mucosal healing, the guideline stated. Mucosal healing was defined as resolution of inflammatory changes (Mayo endoscopic subscore 0 or 1), and is key to increasing the likelihood of sustained steroid-free remission and preventing hospitalizations and surgery, the guideline said (conditional recommendation, low-quality evidence).

Once remission is achieved, for patients with mildly active ulcerative proctitis, rectal 5-aminosalicylate (5-ASA) therapies at a dose of 1 g/d are recommended for induction of remission (strong recommendation, high-quality evidence). For moderately to severely active ulcerative colitis, the guideline recommends oral budesonide multi-matrix (MMX) for induction of remission (strong recommendation, moderate-quality evidence).

In patients with previously moderately to severely active disease who have achieved remission but in whom 5-ASA therapy previously failed and who are now on anti-tumor necrosis factor (TNF) therapy, the guideline recommended against both concomitant 5-ASA (conditional recommendation, low-quality evidence) and systemic corticosteroids (strong recommendation, moderate-quality evidence) for maintenance of remission.

For patients with previously moderately to severely active disease in remission from corticosteroids, thiopurines are recommended for maintenance of remission compared with no treatment or corticosteroids (conditional recommendation, low-quality evidence). The guideline also recommended against using methotrexate for maintenance of remission (conditional recommendation, low-quality evidence). Instead, it recommended continuing anti-TNF therapy using adalimumab, golimumab, or infliximab to maintain remission after anti-TNF induction in patients with previously moderately to severely active disease (strong recommendation, moderate-quality evidence).

The guideline also stressed follow-up for colorectal cancer screening and recommended that screening and subsequent surveillance colonoscopy begin eight years after diagnosis to assess for dysplasia in individuals with ulcerative colitis that involves more than the rectum. Patients with UC and primary sclerosing cholangitis should undergo a screening colonoscopy when diagnosed and surveillance annually, the guideline said. Surveillance colonoscopies should be performed at one- to three-year intervals based on the combined risk factors for colorectal cancer and findings from previous colonoscopies.

“Patients with [ulcerative colitis] are at an increased risk of [colorectal cancer] and should undergo surveillance colonoscopy focused on identifying and removing precancerous dysplasia,” the guideline said. “The evolution of technology has resulted in more directly visualized approaches, removal of endoscopically discrete lesions, and in select patients, active surveillance rather than proctocolectomy.”