American Gastroenterological Association Releases First Pouchitis Management Guideline

Siddharth Singh, MD, MS

Credit: University of Califonia San Diego

The American Gastroenterological Association (AGA) has released the first comprehensive evidence-based guideline on the management of pouchitis.

Published in Gastroenterology, the guideline was devised by a multidisciplinary panel of content experts and guideline methodologists to support practitioners in the management of pouchitis and inflammatory pouch disorders.¹

“As providers we struggle to get insurance approval for medications to treat pouchitis, because it has not been a well-defined or recognized entity. Our intention with this guideline is to help improve access for patients and providers to use these advanced therapies,” said guideline author Siddharth Singh, MD, MS, assistant professor of medicine at the University of California, San Diego, in a press release.²

Despite the benefits of intestinal continuity and improved quality of life, ileal pouch-anal anastomosis (IPAA) is also associated with multiple complications, the most common of which is pouchitis, affecting between 25% and 45% of people with an ileal pouch. Although antibiotics can effectively treat some cases of pouchitis, little is currently known about appropriate prevention, treatment, and management strategies and no comprehensive framework has been established to guide clinical practice.³

To address this knowledge gap, the panel sought to prioritize clinical questions, identify patient-centered outcomes, conduct an evidence synthesis, and develop recommendations for the prevention and treatment of pouchitis and other inflammatory disorders that can occur after colectomy with IPAA for UC. Members of the guideline and evidence synthesis panel were selected based on clinical and methodological expertise and experience and after review of all conflicts of interest.¹

Together, they developed clinically relevant and focused questions about the primary prevention of pouchitis after IPAA, treatment of pouchitis and prevention of recurrent and/or refractory pouchitis, treatment of Crohn-like disease of the pouch, and treatment of cuffitis.¹

A comprehensive search of Ovid MEDLINE, Embase, and Wiley Cochrane Library was conducted using a combination of controlled vocabulary terms and relevant keywords to identify relevant randomized controlled trials and observational studies reporting on the efficacy, effectiveness, and adverse effects of therapies of interest. Pertinent data on patients, definition of disease entity, intervention, outcome definition, and timing of assessment were abstracted from each study.¹

Panelists used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate the certainty of evidence and weigh the magnitude of, and balance among, the benefit and harms of interventions; patients’ values and preferences; and domains of feasibility, acceptability, resource requirements, and impact on health equity. Of note, the panel reached a consensus for all guidelines and made a total of 9 conditional recommendations.²

For physicians caring for patients with ulcerative colitis who undergo proctocolectomy with IPAA, the panel recommends initial treatment of pouchitis with antibiotics, treatment with multi-strain probiotics following an antibiotic course for preventing recurrent pouchitis, cyclical or near continuous antibiotic therapy to treat pouchitis that responds to antibiotics but recurs frequently and shortly after antibiotics are discontinued, and advanced immunosuppressive medications for patients with recurrent pouchitis that does not respond to antibiotics or Crohn-like disease of the pouch.²

Of note, the AGA guideline suggests against the use of antibiotics for primary prevention of pouchitis. Guideline authors did not find enough scientific evidence to recommend for or against the use of probiotics for prevention.²

In patients who develop symptoms due to Crohn-like disease of the pouch, the AGA suggests using corticosteroids and advanced immunosuppressive therapies. In patients who experience symptoms due to cuffitis, the AGA suggests using therapies that have been approved for the treatment of ulcerative colitis, starting with topical mesalamine or topical corticosteroids.¹

“It’s important for patients to know how to care for their pouch if they develop pouchitis, especially if they don’t have access to a healthcare provider that is a pouch specialist. This guideline can help patients understand that pouchitis is a real condition, there is treatment for it, and that they don’t have to live with symptoms,” said Amber Tresca, a patient advocate who has been living with a J-pouch for over 20 years, in a press release about the guideline.²

References:

1. Barnes EL, Agrawal M, Syal G, et al. AGA Clinical Practice Guideline on the Management of Pouchitis and Inflammatory Pouch Disorders. Gastroenterology. https://doi.org/10.1053/j.gastro.2023.10.015
2. American Gastroenterological Association. First comprehensive medical guideline on management of pouchitis released. EurekAlert! December 19, 2023. Accessed December 20, 2023. https://www.eurekalert.org/news-releases/1011113
3. Cleveland Clinic. Pouchitis. Diseases & Conditions. September 20, 2023. Accessed December 20, 2023. https://my.clevelandclinic.org/health/diseases/15484-pouchitis