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In July 2022, the Pan American Crohn's Disease and Colitis Organization (PANCCO) updated its guidelines
for the treatment of ulcerative colitis in adults.
Ulcerative colitis (UC) is a chronic disease of unknown etiology with an intermittent clinical course characterized by
remission and relapse.
This article mainly provides evidence-based guidance and suggestions for the treatment of adult UC, hoping to have some reference help
for your clinical work.
The recommended points for the remission induction section of the guidelines are summarized as follows: 2022 PANCCO Clinical Practice Guidelines:
Induction of Remission in
Adult UC Patients Recommendation 1: For patients with UC, topical (rectal) 5-aminosalicylic acid (5-ASA) therapy is recommended to induce remission
.
(Recommended level: strong; Quality of evidence: low)
Practice points: topical 5-ASA dose to induce remission should be 1 g/day.
Topical steroids may be used as second-line therapy to induce remission
in patients with mild to moderate UC who have failed or are intolerant to topical 5-ASA therapy.
Recommendation 2: Oral 5-ASA therapy is recommended for patients with mildly to moderately active left or extensive lesions to induce clinical and endoscopic remission
.
(Recommended level: strong; Quality of evidence: Low) Practice points: The patient's response
to 5-ASA should be assessed at 4~8 weeks of treatment.
If treatment fails, the need to adjust treatment
should be determined.
The oral dose of 5-ASA to induce remission is at least 2.
4 g/day, and in some cases, ≥3 g/day
.
To improve treatment adherence, formulations that can be given daily as a single dose (if available)
should be preferred.
Recommendation 3: Oral steroids are recommended to induce remission
in patients with moderate to severe UC.
(Recommended level: strong; Quality of evidence: moderate)
Practice points: The patient's responseto oral steroid therapy should be assessed at 2~4 weeks of treatment.
If treatment fails, the need to adjust treatment
should be determined.
The recommended initial dose of oral prednisolone or prednisone is 40~60 mg/day, and once there is a clinical response (up to two weeks), the dose should be gradually reduced until the drug is completely discontinued, and the total duration of medication is not more than 12 weeks
.
Recommendation 4: Budesonide MMX is recommended for induction of remission
in patients with mildly to moderately active UC.
(Recommended level: conditional; Quality of evidence: high)
Practice Points: Budesonide MMX can be used in patientswho do not respond to 5-ASA therapy.
The recommended induction dose for budesonide MMX is 9 mg/day for 8 weeks
.
Recommendation 5: For patients with mild to moderate left-sided or extensively diseased UC, a rectal 5-ASA enema plus oral 5-ASA is recommended for induction of remission
.
(Recommended level: strong; Quality of evidence: very low)
in patients with mildly to moderately active left or extensively diseased UC.
(Recommended level: strong; Quality of evidence: moderate)
Practice Points: mesalazine is preferred over sulfasalazine as the agent of choice because of its lower rate of adverse events.
The patient's response
to 5-ASA should be assessed at 4~8 weeks of treatment.
If treatment fails, the need to adjust treatment
should be determined.
The dose of oral aminosalicylic acid to induce remission should be less than 2.
4 g/day, with the likely ideal dose equal to or greater than 3 g/day
.
1 g sulfasalazine is equivalent to 400 mg of mesalazine
.
Recommendation 7: Intravenous cyclosporine is recommended to induce remission in patients with acute severe UC refractory
to intravenous steroids.
(Recommended level: conditional; Quality of evidence: low)
Practice points: the intravenous dose of cyclosporine should be 2 mg/kg/day.
Intravenous cyclosporine should only be used
by professionals experienced in its use in specialized care centers.
Recommendation 8: Oral tacrolimus is not recommended to induce remission in patients with refractory
or steroid-dependent moderate to severe UC.
(Recommended level: conditional; Quality of evidence: Low)
Recommendation 9: Azathioprine monotherapy is not recommended to induce remission
in people with UC.
(Recommended level: conditional; Quality of evidence: Low)
Recommendation 10: Methotrexate is not recommended to induce remission
in people with UC.
(Recommended level: strong; Quality of evidence: Low)
Recommendation 11: Elimination diet therapy alone is not recommended to induce remission
in people with UC.
(Recommended level: strong; Quality of evidence: very low)
Practice points: In addition to pharmacotherapy, patients with UC should receive nutritional guidance.
The effects of dietary interventions on UC are unclear
.
Recommendation 12: Fecal transplantation is not recommended for inducing remission in patients with drug-refractory
moderate to severe UC.
(Recommended level: conditional; Quality of evidence: very low)
Practice Points: As part of a clinical research protocol, fecal bacteria transplantation should be performedin an experienced specialized center.
Recommendation 13: Cannabis-induced remission
induction is not recommended for patients with mild to moderate UC who do not respond to conventional medical therapy.
(Recommended level: conditional; Quality of evidence: low)
Recommendation 14: Antibiotics are not recommended to induce remission in patients with active UC and may be used as adjunctive therapy to usual care
.
(Recommended level: conditional; Quality of evidence: moderate)
Practice Takeaways: The panel warned of the risk of bacterial resistance or Clostridium difficile infection in UC patients who use antibioticsinappropriately.
Recommendation 15: Infliximab is recommended for patients with acute severe UC refractory to intravenous corticosteroids
.
(Recommended level: strong; Quality of evidence: very low)
Recommendation 16: Routine intensive infliximab regimen is not recommended for patients with acute severe UC
.
(Recommended level: conditional; Quality of evidence: very low)
Practice points: the intensive regimen of infliximab can be considered as acute remedial treatment.
In multiple-dose regimens, an initial dose of 5 mg/kg of infliximab is superior to 10 mg/kg
.
Recommendation 17: Patients with moderate to severe UC are recommended to induce remission
with anti-TNF-α (tumor necrosis factor-α) preparations (infliximab, adalimumab, and golimumab), anti-integrin-alpha4β7 preparations (vedecrolizumab), or IL-12/23 inhibitors (ustekinumab) biotherapy.
(Recommended level: strong; Quality of evidence: very low)
recommendation 18: Tofacitinib (a JAK inhibitor) is recommended to induce remission
in patients with moderate to severe UC.
(Recommended level: strong; Quality of evidence: very low)
Practice points: tofacitinib should be used with caution in patients with risk factors for venous thromboembolism.
First-line agents
should be selected based on comorbidities, age, risk factors, cost, and patient preference.
Recommendation 19: Ulactekinumab or tofacitinib is recommended to induce clinical remission
in patients with no initial response, no resolution, or intolerance to prior anti-TNF therapy.
(Recommended level: conditional; Quality of evidence: very low)
Recommendation 20: Vedelizumab is recommended to induce clinical remission
in patients treated with prior anti-TNF therapy when ustekinumab or tofacitinib are not available.
(Recommended level: conditional; Quality of evidence: low).
References: Juliao-Baños F, Grillo-Ardila C F, Alfaro I, et al.
Update of the PANCCO clinical practice guidelines for the treatment of ulcerative colitis in the adult population[J].
Revista de Gastroenterología de México (English Edition), 2022.
