The American Gastroenterological Association (AGA) has produced new guidelines to support the management of patients with moderate to severe ulcerative colitis (UC).
The guideline sought to address the medical management of adult outpatients as well as those who are hospitalised with the condition. There are 11 recommendations and for each one there is an estimate of the strength of the recommendation (that is, strong, conditional or no recommendation) and the quality of the associated evidence (for example, high/moderate/low/very low/or evidence gap). Interestingly, only one recommendation was deemed as “strong” and based on moderate quality evidence. In contrast the majority of recommendations were associated with low or very low-quality evidence.
The best evidence was for the use of a biologic such as infliximab, adalimumab etc for treatment in an outpatient setting for those with moderate to severe disease. This was based on evidence from 16 randomised trials indicating that a biologic can induce disease remission within 6-8 weeks compared to placebo. In contrast the guideline does not recommend the use of methotrexate to induce remission or as a maintenance therapy although this is based on very low-quality evidence.
Despite the desire for high-quality, evidence-based guidelines, there are still too many unknowns in the management of patients with moderate to severe ulcerative colitis.
Feuerstein JD et al. AGA clinical practice guidelines on the management of moderate to severe ulcerative colitis. Gastroenterology 2020;158:1450-61.