AGA Guideline Update on Pharmacologic Ulcerative Colitis Treatment

A multidisciplinary panel of experts released the American Gastroenterological Association (AGA) living guideline to support clinicians in the pharmacologic management of moderate to severe UC. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework to prioritize clinical questions, identify patient-centered outcomes, conduct an evidence synthesis, and develop pharmacologic management of moderate to severe UC.

The guideline includes 14 pharmacologic recommendations. Notable recommendations include the following:

In adult outpatients with moderate to severe UC, the AGA recommends use of infliximab, golimumab, vedolizumab, tofacitinib, upadacitinib, ustekinumab, ozanimod, etrasimod, risankizumab, and guselkumab, and suggests the use of adalimumab, filgotinib, and mirikizumab over no treatment.

In patients who are naïve to advanced therapies, the AGA suggests using a higher-efficacy medication (eg, infliximab, vedolizumab, ozanimod, etrasimod, upadacitinib, risankizumab, and guselkumab) or an intermediate-efficacy medication (eg, golimumab, ustekinumab, tofacitinib, filgotinib, and mirikizumab) rather than a lower-efficacy medication (eg, adalimumab).

In patients who have previously been exposed to one or more advanced therapies, particularly tumor necrosis factor (TNF)-α antagonists, the AGA suggests using a higher-efficacy medication (eg, tofacitinib, upadacitinib, and ustekinumab) or an intermediate-efficacy medication (eg, filgotinib, mirikizumab, risankizumab, and guselkumab) rather than a lower-efficacy medication (eg, adalimumab, vedolizumab, ozanimod, and etrasimod).

In adult outpatients with moderate to severe UC, the AGA suggests against using thiopurine monotherapy for induction of remission, and instead suggests using thiopurine monotherapy over no treatment for maintenance of (typically corticosteroid-induced) remission. The AGA suggests against using methotrexate monotherapy, for induction or maintenance of remission.

In adult outpatients with moderate to severe UC, the AGA suggests the use of infliximab, adalimumab, and golimumab in combination with an immunomodulator over corresponding monotherapy. However, the AGA makes no recommendation in favor of, or against, the use of non-TNF antagonist biologics in combination with an immunomodulator over non-TNF biologic alone.

In patients with UC who are in corticosteroid-free clinical remission for at least six months on combination therapy of TNF antagonists and an immunomodulator, the AGA suggests against withdrawal of TNF antagonists, but makes no recommendation in favor of or against withdrawing immunomodulators.

In adult outpatients with moderate to severe UC who have failed 5-aminosalicylates and have escalated to therapy with immunomodulators or advanced therapies, the AGA suggests stopping 5-aminosalicylates.

In adult outpatients with moderate to severe UC, the AGA suggests early use of advanced therapies and/or immunomodulator therapy, rather than gradual step-up after failure of 5-aminosalicylates.