Use mesalamin in standard dose rather than low dose in patients with extensive mild-to-moderate ulcerative colitis

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