Management of ulcerative colitis: a summary of recommendations from NICE

  • NICE

  • curated by Pavankumar Kamat
  • Clinical Guidance Summaries
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Guideline name: Ulcerative colitis: management [NG130]

Update type: New guideline

Published: May 2019

Takeaway

  • NICE has issued a guideline focusing on the management of ulcerative colitis (UC) in children, young people and adults with the aim of guiding clinicians to provide consistent high-quality care as well as advice and support to patients.
  • The recommendations in this summarised version of the guideline do not cover the surgical management of UC.

Information and support

  • Discuss the nature of the disease, treatment options (including information on side effects) and monitoring with the patient, their family members or carers (as appropriate), and within the multidisciplinary team.
  • Information on the risk of developing colorectal cancer and about colonoscopic surveillance should be conveyed to patients, and their family members or carers (as appropriate).

Inducing remission

Mild-to-moderate UC

Proctitis

  • Offer a topical aminosalicylate as first-line therapy for a mild-to-moderate first presentation or inflammatory exacerbation of proctitis.
  • Add an oral aminosalicylate if remission is not achieved in within 4 weeks.
  • A time-limited course of a topical or an oral corticosteroid may be considered if further treatment is necessary.
  • For individuals declining a topical aminosalicylate:
    • Consider an oral aminosalicylate as a first-line agent, and explain that its efficacy is lower than a topical aminosalicylate
    • If remission is not achieved within 4 weeks, consider addition of a time-limited course of a topical or an oral corticosteroid.
  • If aminosalicylates are not tolerated, consider a time-limited course of a topical or an oral corticosteroid.

Proctosigmoiditis and left-sided UC

  • To induce remission in people with a mild-to-moderate first presentation or inflammatory exacerbation of proctosigmoiditis or left-sided ulcerative colitis, offer a topical aminosalicylate as first-line treatment. 
  • If remission is not achieved in within 4 weeks, consider addition of a high-dose oral aminosalicylate to the above regimen or switching to a high-dose oral aminosalicylate and a time-limited course of a topical corticosteroid.
  • If further treatment is required, discontinue topical treatments and offer an oral aminosalicylate and a time-limited course of an oral corticosteroid.
  • For those declining topical therapies, consider a high-dose oral aminosalicylate alone (not as effective as topical aminosalicylate). If remission is not achieved in within 4 weeks, add a time-limited course of an oral corticosteroid to the regimen.
  • If aminosalicylates are not tolerated, consider a time-limited course of a topical or an oral corticosteroid.

Extensive disease

  • Offer a topical aminosalicylate and a high-dose oral aminosalicylate as first-line treatment.
  • If remission is not achieved within 4 weeks, discontinue topical aminosalicylate and start a high-dose oral aminosalicylate with a time-limited course of an oral corticosteroid.
  • If aminosalicylates are not tolerated, consider a time-limited course of an oral corticosteroid.
  • For guidance on biologics and Janus kinase inhibitors for treating moderate to severely active UC, refer NICE technology appraisal guidance on infliximab, adalimumab and golimumab, vedolizumab, and tofacitinib.

Severe UC: all extents of disease

  • Multidisciplinary approach
    • Collaborative treatment and management by a gastroenterologist and a colorectal surgeon are recommended.
    • The multidisciplinary team treating severe UC should have a composition appropriate for the age of the patient.
    • A paediatrician with specialising in gastroenterology should be consulted when treating a child or young person.
    • Obstetrics and gynaecology team should be included when treating a pregnant woman.

Maintaining remission

Proctitis and proctosigmoiditis

  • Consider the following options to maintain remission after a mild-to-moderate inflammatory exacerbation:
    • Topical aminosalicylate alone (daily or intermittent) or
    • Oral aminosalicylate + topical aminosalicylate (daily or intermittent) or
    • Oral aminosalicylate alone (not as effective as the above two).

Left-sided and extensive UC

  • To maintain remission after a mild-to-moderate exacerbation
    • For adults: offer low maintenance dose of an oral aminosalicylate.
    • For children: offer an oral aminosalicylate.
  • Patient's preferences (carers or parents in the case of children), side effects and cost should be considered when selecting the oral aminosalicylate.

All extents of disease

  • Consider oral azathioprine or mercaptopurine in the following cases;
    • There have been ≥2 exacerbations in 12 months requiring systemic corticosteroids or
    • Aminosalicylates were unable to maintain remission.
  • For remission after a single episode of acute severe UC:
    • Consider oral azathioprine or oral mercaptopurine.
    • If the above two are contraindicated, consider oral aminosalicylates.
  • Once-daily dosing regimen for oral aminosalicylates is preferable when used for maintaining remission.

Pregnant women

  • It is important to have effective communication and information-sharing across specialties when treating pregnant women.
  • Pregnant women should be communicated the benefits and risks of receiving or not receiving treatment and risk of an acute severe inflammatory exacerbation requiring admission.

Monitoring

Bone health

  • For adults with a risk of fragility fracture, refer NICE guideline on osteoporosis.
  • For children, monitoring is required in the following cases:
    • During chronic active disease
    • Following treatment with systemic corticosteroids
    • Following recurrent active disease.

Growth and pubertal development in children and young people

  • Height and body weight of children and young people with UC should be assessed against expected values on centile charts (and/or z scores) at defined intervals.
  • Pubertal development in young people with UC should be monitored using the principles of Tanner staging.
  • If a young patient with UC has slow pubertal progress or has not developed age-appropriate pubertal features, consider referral to a secondary care paediatrician.

This summary is reviewed by Prof. Rishabh Prasad MBBS, MA, MSC, FRCGP, FFCI, FRSA

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