The American Gastroenterological Association (AGA)
has published a new clinical guideline for the medical management of patients
with mild-to-moderate ulcerative colitis (UC).
According to the guideline, mild-to-moderate UC is
characterized by mild or moderate rectal bleeding, <4-6 bowel movements in a
day, absence of constitutional symptoms, low overall inflammatory burden, and
absence of features suggestive of high inflammatory activity. However, the
guideline also cautions that those who have more frequent bowel movements, more
prominent rectal bleeding or greater overall inflammatory burden should be
considered to have moderate disease.
Key recommendations include:
·
In patients who have extensive mild-moderate disease, use
of either standard dose mesalamine (2-3 g/day) or diazo-bonded 5-aminosalicylic
acid (5-ASA) is recommended instead of low dose mesalamine, sulfasalazine or no
treatment (Strong recommendation, moderate quality evidence).
·
Add rectal mesalamine to oral 5-ASA in patients with
extensive or left-sided disease (Conditional recommendation, moderate
quality evidence).
·
In patients with mild–moderate UC with suboptimal
response to standard-dose mesalamine or diazo-bonded 5-ASA or with moderate
disease activity, use high-dose mesalamine (>3 g/d) with rectal mesalamine. (Conditional
recommendation, moderate-quality evidence [induction of remission], low-quality
evidence [maintenance of remission])
·
Oral mesalamine should be administered once-daily rather
than multiple times during the day (Conditional recommendation, moderate
quality evidence).
·
Standard-dose oral mesalamine or diazo-bonded 5-ASA is
recommended, rather than budesonide MMX or controlled ileal-release budesonide
for induction of remission (Conditional recommendation, low quality of
evidence).
·
In mild–moderate ulcerative proctosigmoiditis or
proctitis, use of mesalamine enemas (or suppositories) rather than oral
mesalamine is recommended (Conditional recommendation, very-low-quality
evidence).
·
For patients with mild–moderate ulcerative
proctosigmoiditis who opt for rectal therapy over oral therapy, use mesalamine
enemas rather than rectal corticosteroids (Conditional recommendation,
moderate-quality evidence).
·
Mesalamine suppositories are recommended for patients
with mild–moderate ulcerative proctitis who prefer rectal therapy over oral
therapy (Strong recommendation, moderate-quality evidence).
·
In cases of mild to moderate ulcerative proctosigmoiditis
or proctitis being treated with rectal therapy who are intolerant of or
refractory to mesalamine suppositories, use rectal corticosteroid therapy
rather than no therapy for induction of remission (Conditional
recommendation, low-quality evidence).
·
Add either oral prednisone or budesonide MMX in patients
with mild–moderate disease, which is refractory to optimized oral and rectal
5-ASA, regardless of disease extent (Conditional recommendation, low-quality
evidence).
The guideline makes no
recommendations for the use of probiotics or curcumin in these patients (No
recommendation, knowledge gap). It also says that fecal microbiota
transplantation should be performed only in the context of a clinical trial in
patients with mild to moderate disease without Clostridium difficile infection (No
recommendation for treatment of ulcerative colitis, knowledge gap).
(Source: American Gastroenterological Association Press
Release, Jan. 10, 2019)
Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical
Associations in Asia and Oceania
(CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA
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