Guidelines

Clinical Management Guidelines

Since the advent of evidence-based medicine in the 1980s, clinical practice guidelines have gradually emerged as indispensable reference documents, collating and summarizing available data and promoting proven interventions. In the US, two professional societies publish guidelines for the management of ulcerative colitis (UC): the American College of Gastroenterology (ACG) and the American Gastroenterological Association (AGA). The latest ACG guidelines on UC management were published in 2019, while the AGA released one set of guidelines for the management of mild to moderate UC in 2019, followed in 2020 by another set for the management of moderate to severe UC.

2019 ACG Guidelines for UC in Adults

The 2019 update to the ACG guidelines addresses the diagnosis, treatment and overall management of adult patients with UC. Since 2010, when the ACG last published these guidelines, the management of UC has become more complex, due to the introduction of new therapies and treatment approaches. For example, one of many important points from the updated guidelines is recognizing that treatment decisions should take into account patient prognosis in addition to disease severity and extent. Other important additions include recommendations concerning usage of golimumab, vedolizumab and tofacitinib – treatments approved for UC since the last set of guidelines were released. Upadacitinib was not yet approved at the time of the guidelines but is considered standard of practice for patients with moderate to severe UC. In total, the updated guidelines include 49 recommendations based on GRADE criteria (Table 7-1) and 54 summary statements. The updated guidelines aim to help practitioners incorporate these new therapies and treatment approaches, with the optimal goal of management being sustained and durable periods of steroid-free remission, accompanied by psychosocial support, normal health-related quality of life, prevention of morbidity and prevention of cancer.

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2019 AGA Guidelines for Mild to Moderate UC in Adults

The AGA released its clinical guidelines for the management of adult outpatients with mild to moderate UC. Because they cover only mild and moderate UC and are not concerned with diagnosis, these guidelines are narrower in scope than the 2019 ACG guidelines, focusing largely on oral and topical aminosalicylate (5-ASA) drugs, rectal corticosteroids and oral budesonide. Less conventional therapeutic approaches, including probiotics, curcumin and fecal microbiota transfer, are also addressed. Similar to the ACG guidelines, the AGA guidelines are developed using the GRADE methodology. A total of 13 recommendations are presented in the 2019 AGA guidelines, including specific recommendations for patients with proctosigmoiditis or isolated proctitis (Table 7-2).

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2020 AGA Guidelines for Moderate to Severe UC in Adults

In 2020, the AGA released its clinical guidelines for the management of adult outpatients with moderate to severe UC and hospitalized patients with acute severe UC. Similar to the 2019 AGA guidelines, these guidelines are narrower in scope than the 2019 ACG guidelines, focusing primarily on immunomodulators, biologics and small molecules. In its review of evidence, the 2020 AGA guidelines also included a network meta-analysis – a single analysis combining direct and indirect evidence across a network of three or more trials– comparing the efficacy and safety of infliximab, adalimumab, golimumab, vedolizumab, tofacitinib and ustekinumab. At the time of these guidelines, upadacitinib was not yet approved for the treatment of moderate to severe UC. Thus, while the 2020 AGA recommendations (Table 7-3) remain broadly concordant with those from the ACG guidelines, several discrepancies exist.

For example, based on the VARSITY trial and the above-mentioned network meta-analysis, the 2020 AGA guidelines recommend infliximab or vedolizumab over adalimumab for biologic-naïve patients, which the ACG guidelines do not. Furthermore, the 2020 AGA guidelines recommend tofacitinib or ustekinumab for TNF blocker-experienced patients, in contrast to the ACG guidelines which were published before the approval of ustekinumab in 2019 and which therefore recommend tofacitinib or vedolizumab for this patient group.

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