Ulcerative Colitis in Adults

Publication Date: February 1, 2019
Last Updated: March 14, 2022

Recommendations

Diagnosis, assessment, and prognosis of ulcerative colitis

1. We recommend stool testing to rule out Clostridioides difficile in patients suspected of having UC. (Strong  “We recommend”, Very low)
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2. We recommend against serologic antibody testing to establish or rule out a diagnosis of UC. (Strong  “We recommend”, Very low)
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3. We recommend against serologic antibody testing to determine the prognosis of UC. (Strong  “We recommend”, Very low)
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Goals for managing patients with ulcerative colitis

4. 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. (Conditional (weak)  “We suggest”, Low)
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5. We suggest fecal calprotectin (FC) as a surrogate for endoscopy when endoscopy is not feasible or available to assess for mucosal healing. (Conditional (weak)  “We suggest”, Very low)
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Induction of remission in mildly active ulcerative colitis

6. In patients with mildly active ulcerative proctitis, we recommend rectal 5-ASA therapies at a dose of 1 g/d for induction of remission. (Strong  “We recommend”, High)
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7. 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. (Strong  “We recommend”, Moderate)
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8. 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. (Conditional (weak)  “We suggest”, Low)
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9. 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. (Strong  “We recommend”, Moderate)
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10. In patients with mildly active extensive colitis, oral 5-ASA at a dose of at least 2 g/d is recommended to induce remission. (Strong  “We recommend”, Moderate)
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11. In patients with UC of any extent who fail to respond to 5-ASA therapy, we recommend oral systemic corticosteroids to induce remission. (Strong  “We recommend”, Low)
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12. 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. (Conditional (weak)  “We suggest”, Low)
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13. 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. (Conditional (weak)  “We suggest”, Very low)
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14. In patients with mildly to moderately active UC not responding to oral 5-ASA, we recommend the addition of budesonide multi-matrix (MMX) 9 mg/d to induce remission. (Strong  “We recommend”, Moderate)
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15. 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, since efficacy and safety are no different. (Strong  “We recommend”, Moderate)
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Maintenance of remission in patients with previously mildly active ulcerative colitis

16. In patients with mildly active ulcerative proctitis, we recommend rectal 5-ASA at a dose of 1 g/d to maintain remission. (Strong  “We recommend”, Moderate)
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17. 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. (Strong  “We recommend”, Moderate)
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18. We recommend against systemic corticosteroids for maintenance of remission in patients with UC. (Strong  “We recommend”, Moderate)
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Induction of remission in moderately to severely active ulcerative colitis

19. In patients with moderately active UC, we recommend oral budesonide MMX for induction of remission. (Strong  “We recommend”, Moderate)
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20. In patients with moderately to severely active UC of any extent, we recommend oral systemic corticosteroids to induce remission. (Strong  “We recommend”, Moderate)
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21. In patients with moderately to severely active UC, we recommend against monotherapy with thiopurines or methotrexate for induction of remission. (Strong  “We recommend”, Low)
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22. In patients with moderately to severely active UC, we recommend anti-TNF therapy using adalimumab, golimumab, or infliximab for induction of remission. (Strong  “We recommend”, High)
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23. In patients with moderately to severely activeUCwho 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. (Conditional (weak)  “We suggest”, Low)
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24. When infliximab is used as induction therapy for patients with moderately to severely active UC, we recommend combination therapy with a thiopurine. (Strong  “We recommend”, )
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  • azathioprine

(, Moderate)
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25. In patients with moderately to severely active UC, we recommend vedolizumab for induction of remission. (Strong  “We recommend”, Moderate)
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26. In patients with moderately to severely active UC who have previously failed anti-TNF therapy, we recommend vedolizumab for induction of remission. (Strong  “We recommend”, Moderate)
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27. In patients with moderately to severely active UC, we recommend tofacitinib 10 mg orally b.i.d. for 8 wk to induce remission. (Strong  “We recommend”, Moderate)
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28. In patients with moderately to severely active UC who have previously failed anti-TNF therapy, we recommend tofacitinib for induction of remission. (Strong  “We recommend”, Moderate)
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29. 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. (Conditional (weak)  “We suggest”, Very low)
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Maintenance of remission in patients with previously moderately to severely active ulcerative colitis

30. 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. (Conditional (weak)  “We suggest”, Low)
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31. We recommend against systemic corticosteroids for maintenance of remission in patients with UC. (Strong  “We recommend”, Moderate)
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32. 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. (Conditional (weak)  “We suggest”, Low)
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33. In patients with previously moderately to severely active UC now in remission, we recommend against using methotrexate for maintenance of remission. (Conditional (weak)  “We suggest”, Low)
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34. 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. (Strong  “We recommend”, Moderate)
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35. We recommend continuing vedolizumab to maintain remission in patients with previously moderately to severely active UC now in remission after vedolizumab induction. (Strong  “We recommend”, Moderate)
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36. We recommend continuing tofacitinib for maintenance of remission in patients with previously moderately to severely active UC now in remission after induction with tofacitinib. (Strong  “We recommend”, Moderate)
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Management of the hospitalized patient with acute severe ulcerative colitis

37. In patients with ASUC, we recommend DVT prophylaxis to prevent VTE. (Strong  “We recommend”, Low)
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38. In patients with ASUC, we recommend testing for Clostridioides difficile infection (CDI). (Strong  “We recommend”, Moderate)
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39. In patients with ASUC and concomitant CDI, we recommend treatment of CDI with vancomycin instead of metronidazole. (Strong  “We recommend”, Low)
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40. We recommend against the routine use of broad-spectrum antibiotics in the management of ASUC. (Strong  “We recommend”, Low)
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41. We suggest against total parenteral nutrition for the purpose of bowel rest in ASUC. (Conditional (weak)  “We suggest”, Very low)
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42. In patients with ASUC, we recommend a total of 60 mg/d of methylprednisolone or hydrocortisone 100mg 3 or 4 times per day to induce remission. (Strong  “We recommend”, Low)
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43. In patients with ASUC failing to adequately respond to intravenous corticosteroids by 3–5 days we recommend medical rescue therapy with infliximab or cyclosporine. (Strong  “We recommend”, Moderate)
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44. In patients with ASUC who achieve remission with infliximab treatment, we recommend maintenance of remission with the same agent. (Strong  “We recommend”, Moderate)
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45. In patients with ASUC who achieve remission with cyclosporine treatment, we suggest maintenance of remission with thiopurines. (Conditional (weak)  “We suggest”, Low)
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46. In patients with ASUC who achieve remission with cyclosporine treatment, we suggest maintenance of remission with vedolizumab. (Conditional (weak)  “We suggest”, Very low)
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Colorectal cancer prevention in ulcerative colitis

47. We suggest colonoscopic screening and surveillance to identify neoplasia in patients with UC of any extent beyond the rectum. (Conditional (weak)  “We suggest”, Very low)
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48. 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. (Strong  “We recommend”, Low)
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49. 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. (Conditional (weak)  “We suggest”, Low)
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Recommendation Grading

Overview

Title

Ulcerative Colitis in Adults

Authoring Organization

American College of Gastroenterology

Publication Month/Year

February 1, 2019

Last Updated Month/Year

June 12, 2023

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

These guidelines indicate the preferred approach to the management of adults with UC and represent the official practice recommendations of the American College of Gastroenterology. 

Target Patient Population

Patients with ulcerative colitis

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Diagnosis, Management, Treatment

Diseases/Conditions (MeSH)

D003093 - Colitis, Ulcerative, D015212 - Inflammatory Bowel Diseases, D007166 - Immunosuppressive Agents, D000893 - Anti-Inflammatory Agents

Keywords

inflammatory bowel disease, ulcerative colitis, autoinflammatory

Source Citation

Rubin, David T. MD, FACG; Ananthakrishnan, Ashwin N. MD, MPH; Siegel, Corey A. MD, MS; Sauer, Bryan G. MD, MSc (Clin Res), FACG (GRADE Methodologist); Long, Millie D. MD, MPH, FACG. ACG Clinical Guideline, American Journal of Gastroenterology: March 2019 - Volume 114 - Issue 3 - p 384-413 doi: 10.14309/ajg.0000000000000152