Management of Moderate to Severe Ulcerative Colitis

Publication Date: November 19, 2024
Last Updated: November 21, 2024

Objective

Objective

This patient guideline summarizes key takeaways from the American Gastroenterological Association (AGA) guideline for management of moderate to severe ulcerative colitis. The purpose of this guideline is to provide new evidence-based recommendations to guide patients and caregivers in making informed decisions regarding their treatment plans.

Overview

Overview

  • Ulcerative colitis (UC) is a long-lasting inflammatory bowel disease. Its peak onset is in early adulthood. If left untreated, it leads to periods of relapse (flare-ups) and remission (symptom improvement).
  • There are various categories of drugs used to manage moderate to severe ulcerative colitis. Among these are biologics and immunomodulators.
  • Biologics are drugs derived from living organisms — for example, derived from proteins.
  • Immunomodulators are drugs that alter the immune system, either to enhance its ability to kill cancer cells or reduce its ability to attack healthy tissues, as in ulcerative colitis.
  • Treatment has two phases:
    • induction: starting the treatment
    • maintenance of remission: keeping the condition under control.
  • This patient guideline is specific for adult outpatients (persons who receive medical services at a healthcare facility but do not require overnight stays) who have moderate to severe disease.

Management

Management

  • In adult outpatients with moderate-to-severe ulcerative colitis, the use of the following agents is recommended:
    • infliximab
    • golimumab
    • vedolizumab
    • tofacitinib
    • upadacitinib
    • ustekinumab
    • ozanimod
    • etrasimod
    • Risankizumab
    • guselkumab
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  • In adult outpatients with moderate-to-severe ulcerative colitis, the following agents are suggested:
    • adalimumab
    • filgotinib
    • mirikizumab
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  • In adult outpatients with moderate-to-severe ulcerative colitis who have not yet taken any advanced therapies, HIGHER efficacy medication (infliximab, vedolizumab, ozanimod, etrasimod, upadacitinib, risankizumab, guselkumab) OR an INTERMEDIATE efficacy medication (golimumab, ustekinumab, tofacitinib, filgotinib, mirikizumab), should be used rather than a LOWER efficacy medication (adalimumab).
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In adult outpatients with moderate-to-severe ulcerative colitis, the use of thiopurine monotherapy for induction of remission is NOT recommended.
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  • In adult outpatients with moderate-to-severe ulcerative colitis in remission, thiopurine monotherapy is suggested, rather than no treatment, for maintenance of remission, typically induced by corticosteroids.
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  • In adult outpatients with moderate-to-severe ulcerative colitis, methotrexate monotherapy should NOT be used for induction or maintenance of remission.
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  • In adult outpatients with moderate-to-severe ulcerative colitis, infliximab in combination with an immunomodulator is suggested over infliximab or an immunomodulator alone.
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  • In adult outpatients with moderate-to-severe ulcerative colitis, the use of adalimumab or golimumab in combination with an immunomodulator is suggested over adalimumab, golimumab or immunomodulator monotherapy.
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  • In adult outpatients with moderate-to-severe ulcerative colitis, no recommendation can be made regarding the use of non-TNF antagonist biologics in combination with an immunomodulator over non-TNF antagonist biologics alone.
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  • In patients with ulcerative colitis who are in corticosteroid-free clinical remission for at least 6 months on combination therapy of TNF antagonists and an immunomodulator, no recommendation can be made regarding withdrawing immunomodulators or continuing combination therapy.
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  • In patients with ulcerative colitis who are in corticosteroid-free clinical remission for at least 6 months on combination therapy of TNF antagonists and an immunomodulator, withdrawal of TNF antagonists is NOT recommended.
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  • In adult outpatients with moderate-to-severe ulcerative colitis, early use of advanced therapies with or without immunomodulator therapy, is suggested, rather than gradual step up after failure of 5-ASAs.
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  • In adult outpatients with moderate-to-severe ulcerative colitis, who have failed 5-ASAs, and have escalated to therapy with immunomodulators or advanced therapies, 5-ASAs may be stopped.
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Abbreviations

  • AGA: American Gastroenterological Association
  • FDA: Food And Drug Administration
  • IBD: Inflammatory Bowel Disease
  • IBS: Irritable Bowel Syndrome
  • UC: Ulcerative Colitis

Source Citation

Siddharth Singh, Edward V. Loftus, Berkeley N. Limketkai, John P. Haydek, Manasi Agrawal, Frank I. Scott, Ashwin N. Ananthakrishnan, AGA Living Clinical Practice Guideline on Pharmacological Management of Moderate-to-Severe Ulcerative Colitis, Gastroenterology, Volume 167, Issue 7, 2024, Pages 1307-1343, ISSN 0016-5085, https://doi.org/10.1053/j.gastro.2024.10.001

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.