Check out the new AGA clinical guideline in Gastroenterology with recommendations for the management of adult outpatients with moderate to severe ulcerative colitis (UC) as well as adult hospitalized patients with acute severe UC. The guideline focuses on immunomodulators, biologics and small molecules to bring on and maintain remission for patients with moderate to severe UC and to decrease the risk of colectomy.

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Learning objectives

Here are five of the most noteworthy recommendations. For all 15 recommendations, review the full guideline.

1. In adult outpatients with moderate to severe UC, AGA recommends using infliximab, adalimumab, golimumab, vedolizumab, tofacitinib or ustekinumab over no treatment. (Strong recommendation: moderate quality evidence)
2. In adult outpatients with moderate to severe UC who are new to biologics, AGA suggests using infliximab or vedolizumab rather than adalimumab for induction of remission. (Conditional recommendation: moderate quality evidence)
   Comment: Patients, particularly those with less severe disease, who place higher value on the convenience of self-administered subcutaneous injection, and a lower value on the relative efficacy of medications, may reasonably chose adalimumab as an alternative.
3. In adult outpatients with moderate to severe UC who have been exposed to infliximab, particularly those who were not responsive, AGA suggests using ustekinumab or tofacitinib, rather than vedolizumab or adalimumab, for induction of remission. (Conditional recommendation: low quality evidence)
   Comment: Patients, particularly those with less severe disease who place higher value on the potential safety of medications, and a lower value on the relative efficacy of medications, may reasonably chose vedolizumab as an alternative.
4. In adult outpatients with moderate to severe UC, AGA suggests early use of biologics with or without immunomodulator therapy, rather than gradual step up after failure of 5-aminosalicylates. (Conditional recommendation: very low quality evidence)
   Comment: Patients, particularly those with less severe disease, who place higher value on the safety of 5-ASA therapy, and lower value on the efficacy of biologic agents, may reasonably choose gradual step therapy with 5-ASA therapy.
   This recommendation supports AGA’s ongoing fight against step therapy treatment where insurers require patients to try and fail medications before agreeing to cover the initial therapy prescribed by their health care provider. AGA believes that patients should be given a clear, equitable and transparent appeals process when subjected to step therapy protocols. Learn more and take action on this issue.
5. In hospitalized adult patients with acute severe UC refractory to intravenous corticosteroids, AGA suggests using infliximab or cyclosporine. (Conditional recommendation: low quality evidence)

Faculty

Siddharth Singh, MD
University of California San Diego
5116 White Emerald Drive
San Diego, CA 92130

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