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