New guidelines for treating patients with ulcerative colitis

New guidelines on diagnosing and managing ulcerative colitis are aimed at helping patients experience sustained periods of remission from the debilitating inflammatory disease while relying less on traditionally used steroids.

“These novel recommendations will help doctors better prevent and care for patients with ulcerative colitis by shifting us from managing flare-ups to better monitoring and preventing them in the first place,” said gastroenterologist David Rubin, MD, chief of gastroenterology, hepatology, and nutrition and co-director of the Digestive Diseases Center at the University of Chicago Medicine.

Rubin led the team of experts that established the guidelines, published in the March issue of The American Journal of Gastroenterology.

Ulcerative colitis (UC), a chronic disease affecting roughly 1 million Americans, is characterized by periods of inflammation and ulcers in the lining of the large intestine. Symptoms include bloody stool, diarrhea, abdominal pain and urgency to go to the bathroom, as well as joint pain.

Rubin says the new management guidelines are geared towards relieving symptoms, preventing harmful secondary effects that may be brought on by treatment, and helping patients into remission. The guidelines place added importance on reducing inflammation and ulcers in the innermost lining of the colon and rectum, which physicians refer to as mucosal healing.

“If we can help heal that critical lining of the bowel, we can decrease the chance a patient has of having another flare-up and keep them in remission,” Rubin said.

The authors also provide new classifications for disease activity — remission, mild, moderate-severe and severe. The guidelines likewise note a specific distinction from previous recommendations on how physicians should decide on a treatment: doctors should now consider both the patient’s inflammatory activity and the prognosis.

“For instance, a patient with mildly active ulcerative colitis who has required steroids and has been previously hospitalized but now in remission, should be evaluated for treatments usually used for patients with moderately to severely active ulcerative colitis,” Rubin explained.

Physicians should always stool test to ensure a patient’s symptoms aren’t caused by Clostridioides difficile (C.diff). Serologic antibody testing is no longer recommended in the guidelines to diagnose ulcerative colitis.

For patients hospitalized with severe ulcerative colitis, the guidelines recommend a flexible sigmoidoscopy (preferably within one day) and treatment with methylprednisolone or hydrocortisone, followed by infliximab or cyclosporine and surgical consultation for those who do not respond to the initial treatment.

New treatments have been developed since the previous guidelines were established in 2010, including several biologic therapies. Rubin says the emerging treatment strategy for UC is using organ-selective treatments, whenever possible, before more systemic therapies. The guidelines also state that additional study of fecal transplantation and probiotics treatment are needed.

The researchers propose stool tests for calprotectin – a type of protein secreted when the colon or rectum is inflamed – as a tool to monitor the effectiveness of treatments and relapse. Rubin says this recommendation will help ensure the test is covered by insurance companies.

Once a patient is in remission, physicians should avoid steroids. Because patients with long-term ulcerative colitis have a higher risk of colorectal cancer, the guidelines recommend patients have colonoscopies beginning eight years after their initial diagnosis, followed by colonoscopies every one to three years, depending on their risk factors. Biopsies from these colonoscopies should be interpreted by an experienced gastrointestinal pathologist.