ACG Releases New Ulcerative Colitis Guideline

Millie Long, MD, MPH

The American College of Gastroenterology (ACG) has released a new guideline for the management of ulcerative colitis (UC) in adult patients.

In an article published by the American Journal of Gastroenterology today, a team of investigators, in collaboration with the Practice Parameters Committee of the ACG, shared a new clinical guideline that addresses the diagnosis, treatment, and overall management of adult patients with UC, as well as guidance towards evaluating hospitalized patients and preventing colorectal cancer (CRC).

According to the investigators, it joins the ACG’s previous guideline focused on preventive care in inflammatory bowel disease (IBD) as instances of clinical recommendations set by the college.

Each of the clinical recommendations provided in the guideline are based on scientific evidence which had been previously evaluated with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process. For instances where evidence was not suitable for GRADE evaluation but met clinical merit consensus, the team addressed the recommendations as “key concept” statements.

Currently, more than 1 million people in the US and Europe are afflicted with UC, a chronic immune-mediated inflammatory disease that affects the large intestines. Though the condition can present at any time in any patient age group, it most prevalently peaks in patients aged 15-30 years old. It is associated with low mortality, but significant morbidity, investigators noted.

“Management of UC must involve a prompt and accurate diagnosis, assessment of the patient’s risk of poor outcomes, and initiation of effective, safe, and tolerable medical therapies,” the team wrote. “The optimal goal of management is a sustained and durable period of steroid-free remission, accompanied by appropriate psychosocial support, normal health-related quality of life (QoL), prevention of morbidity including hospitalization and surgery, and prevention of cancer.”

In a podcast interview hosted by the ACG, guideline co-senior author and University of North Carolina professor Millie Long, MD, MPH, provided some of the key guideline updates, including the recommendation of continued Clostridium difficile (C. difficile) testing in susceptible patients; basing disease severity diagnosis on bleeding rate, bowel normalization, and inflammation; and treating mild to moderate outpatient UC with combined oral and topical therapy in applicable patients.

She also advocated for the avoidance of recurrent steroid therapy.

“The need for steroids twice a year refers to inflammation not being fully healed,” Long explained. “We haven’t treated that patient to reach our target of clinical remission, as well as endoscopic remission.”

Indeed, investigators concluded that appropriate UC management calls for successful clinical and endoscopic remission, with a steroid-free maintenance strategy proceeding remission. Physicians’ therapy choices should be based on disease activity, severity, inflammation extent, and prognosis, they wrote—and vary from oral, topic, and systemic therapies, as well as invasive options.

“When possible and appropriate based on individual clinical factors, organ-specific treatments can be used before systemic therapies,” they wrote. “In general, the induction therapy selected directs the choice of maintenance therapy.”

As patients with UC are at a heightened risk of developing CRC, the guideline calls for surveillance colonoscopy fixed on identifying and removing precancerous dysplasia.

“Using appropriate secondary prevention (screening and surveillance) is necessary at this time to prevent CRC in patients with long-standing UC,” investigators noted.

Evolving technology has given physicians better tools to actively surveil, directly approach, and address issues such as endoscopically discrete lesions.