Recommendations for Treatment of Ulcerative Colitis: AGA Guidelines

American Gastroenterological Association (AGA) has released its guidelines on the management of moderate to severe ulcerative colitis (UC)The guidelines have been recently published in Gastroenterology.

Joseph D. Feuerstein, M.D., from the Beth Israel Deaconess Medical Center in Boston, and colleagues developed guidelines for medical management of adult outpatients with moderate-to-severe UC.

The authors recommend using infliximab, adalimumab, golimumab, vedolizumab, tofacitinib, or ustekinumab over no treatment in adult outpatients with moderate-to-severe UC for induction and maintenance of remission. Infliximab or vedolizumab are recommended over adalimumab for induction of remission in adult outpatients with moderate-to-severe UC who are naive to biologic agents; tofacitinib should only be used in the setting of a clinical or registry study. Ustekinumab or tofacitinib are suggested rather than vedolizumab or adalimumab for induction of remission in adult outpatients with moderate-to-severe UC who have previously been exposed to infliximab, particularly those with primary nonresponse. Thiopurine monotherapy is not recommended for induction of remission in adult outpatients with active moderate-to-severe UC. For maintenance of remission, thiopurine monotherapy is recommended over no treatment for adult outpatients with moderate-to-severe UC in remission.

• In adult outpatients with moderate to severe UC, the AGA recommends using infliximab, adalimumab, golimumab, vedolizumab, tofacitinib, or ustekinumab over no treatment. (Medications are ordered based on year of approval by the US FDA.)
• In adult outpatients with moderate to severe UC who are naïve to biologic agents, the AGA suggests using infliximab or vedolizumab rather than adalimumab, for induction of remission.
• In adult outpatients with moderate to severe UC who are naïve to biologic agents, the AGA recommends that tofacitinib be only be used in biologic-naive patients in the setting of a clinical or registry study.
• In adult outpatients with moderate to severe UC who have previously been exposed to infliximab, particularly those with primary nonresponse, the AGA suggests using ustekinumab or tofacitinib rather than vedolizumab or adalimumab for induction of remission.
• In adult outpatients with active moderate to severe UC, the AGA suggests against using thiopurine monotherapy for induction of remission. 
• In adult outpatients with moderate to severe UC in remission, the AGA suggests using thiopurine monotherapy rather than no treatment for maintenance of remission. 
• In adult outpatients with moderate to severe UC, the AGA suggests against using methotrexate monotherapy for induction or maintenance of remission.
• In adult outpatients with active moderate to severe UC, the AGA suggests using biologic monotherapy (TNF-α antagonists, vedolizumab, or ustekinumab) or tofacitinib rather than thiopurine monotherapy for induction of remission.
• In adult outpatients with moderate to severe UC in remission, the AGA makes no recommendation in favour of or against using biologic monotherapy or tofacitinib rather than thiopurine monotherapy for maintenance of remission.
• In adult outpatients with moderate to severe UC, the AGA suggests combining TNF-α antagonists, vedolizumab or ustekinumab with thiopurines or methotrexate rather than biologic monotherapy.
• In adult outpatients with moderate to severe UC, the AGA suggests combining TNF-α antagonists, vedolizumab, or ustekinumab with thiopurines or methotrexate rather than thiopurine monotherapy
• In adult outpatients with moderate to severe UC, the AGA suggests early use of biologic agents with or without immunomodulator therapy rather than a gradual step up after the failure of 5-ASA.
• In adult outpatients with moderate to severe UC who have achieved remission with biologic agents and/or immunomodulators or tofacitinib, the AGA suggests against continuing 5-ASA for induction and maintenance of remission.
  
• In hospitalized adult patients with ASUC, the AGA suggests using intravenous methylprednisolone dose equivalent of 40–60 mg/d rather than higher dose intravenous corticosteroids
• In hospitalized adult patients with acute severe UC without infections, the AGA suggests against adjunctive antibiotics
• In hospitalized adult patients with ASUC refractory to intravenous corticosteroids, the AGA suggests using infliximab or cyclosporine
• In hospitalized adult patients with acute severe UC being treated with infliximab, the AGA makes no recommendation on routine use of intensive vs standard infliximab dosing

For more details click on the link: https://doi.org/10.1053/j.gastro.2020.01.006