AGA Clinical Practice Guidelines on the Management of Mild-to-Moderate Ulcerative Colitis

These practice recommendations for the management of mild-to-moderate UC were developed using the GRADE framework and in adherence to the standards set forth by the Institute of Medicine for creation of trustworthy guidelines 9, 10. They are intended to reduce practice variation and promote high quality, high value care for patients with mild-to-moderate UC. The current evidence supports use of standard-dose mesalamine or diazo-bonded 5-ASAs for induction and maintenance of remission in patients with extensive mild-moderate UC. Use of combined oral and rectal 5-ASA in patients with extensive disease may improve rates of induction of remission, as may escalation to high-dose oral with rectal 5-ASA in patients with suboptimal response to standard-dose therapy. Those with moderate symptoms may benefit from early use of combined oral and rectal 5-ASA. Patients with proctosigmoiditis or proctitis can be treated with topical mesalamines rather than oral 5-ASA. Those patients with suboptimal response or intolerance to rectal mesalamine may opt to use rectal corticosteroids enemas or foams. Patients with inadequate response to optimized 5-ASA require escalation of therapy to oral prednisone or budesonide MMX. We identified several knowledge gaps and areas for future research in this patient population. Due to evidence gaps, the AGA makes no recommendation for use of probiotics, curcumin, or FMT in patients with mild-moderate UC. Although these modalities appear to be safe, their use risks delaying proven effective therapy with the potential for worsening symptoms or complications. Thus, further studies of their efficacy and safety as compared to the therapies recommended here are urgently needed. Development and validation of risk stratification tools to identify patients who have mild-to-moderate symptoms but who are at high risk of progression to moderate-severe disease and/or colectomy are needed. Better understanding of optimal dosing regimens, in particular which patients might benefit from initial use of high-dose mesalamine or topical mesalamine, is also required. We also identified a need to better understand the relative effectiveness and side effects of budesonide and systemic corticosteroids in patients who do not respond adequately to 5-ASAs. Finally, studies to identify the appropriate patient and timing for escalation to immunomodulators and/or biologics would help with targeting therapy appropriately.