First American Gastroenterological Association living guideline for moderate-to-severe ulcerative colitis

The American Gastroenterological Association (AGA) has released a new clinical guideline on the pharmacological management of moderate-to-severe ulcerative colitis, published today in Gastroenterology. This guideline groups the 12 currently available advanced treatments based on efficacy, to simplify the decision-making process for gastroenterologists and the approximately 1.25 million patients in the U.S. living with ulcerative colitis.

“Since the first biologic treatment for ulcerative colitis was introduced in 2005, 11 advanced therapies have become available in the U.S.,” said guideline author Ashwin N. Ananthakrishnan. “AGA’s updated guidelines integrate both tried-and-true treatments and the latest advancements, offering patients and providers the most current recommendations for managing moderate-to-severe ulcerative colitis.”

To streamline treatment selection, AGA categorized drugs with similar efficacy into "efficacy buckets" that allow clinicians to consider a range of effective treatments based on the likelihood of inducing remission, regardless of the drug’s mechanism. Comparative efficacy recommendations in the guideline are based on a systematic review and network meta-analysis (Comparative Efficacy of Advanced Therapies for Management of Moderate-to-Severe Ulcerative Colitis: 2024 American Gastroenterological Association Evidence Synthesis - Gastroenterology) of published evidence. Using this rigorous process resulted in practical, trustworthy guidance to help patients and clinicians evaluate multiple factors to tailor care, rather than selecting a single “best” treatment.

Key factors influencing treatment decisions include a patient’s risk of disease complications, disease severity, and other considerations such as comorbidities, age, safety risks, and pregnancy status. Additionally, prior treatment history can impact the effectiveness of subsequent therapies, underscoring the importance of personalized treatment planning.

Treatment recommendations:

• AGA recommends patients with moderate-to-severe ulcerative colitis start with advanced therapies and/or immunomodulators over a step-up approach following 5-aminosalicylates (5-ASA) failure.

• For patients who have not previously received advanced therapies, the medications with the highest efficacy include infliximab, vedolizumab, ozanimod, etrasimod, upadacitinib, risankizumab and guselkumab.

• Among patients with prior exposure to advanced therapies, particularly those who have experienced TNF antagonist failure, the medications with the highest efficacy are tofacitinib, upadacitinib, and ustekinumab.

As a living guideline, semiannual reviews of this body of evidence will be conducted by the authors, and recommendations will be updated when indicated.

Understanding ulcerative colitis

There are two main types of inflammatory bowel disease (IBD)-ulcerative colitis and Crohn’s disease. Ulcerative colitis causes inflammation (swelling) and sores (called ulcers) in the large intestine (colon and rectum) and may affect part or all of the large intestine. Ulcerative colitis can happen at any age, but it is more likely to develop in people between the ages of 15 and 40. While there is no cure for ulcerative colitis, there are many options to help treat it, and the medications described in this AGA guideline can lead to remission (periods of no symptoms). 

Reference:

Siddharth Singh, Edward V. Loftus, AGA Living Clinical Practice Guideline on Pharmacological Management of Moderate-to-Severe Ulcerative Colitis, Gastroenterology, DOI:10.1053/j.gastro.2024.10.001.