Ulcerative colitis (UC) is the most common type of inflammatory bowel disease, affecting almost 2 million people in the United States. The disease is characterized by inflammation and ulceration of the colon. It’s typical for patients to have relapsing and remitting symptoms of bloody stools, stomach cramping and urgency of bowel movements.

UC can significantly affect quality of life and be associated with psychological conditions. Complications include dehydration, toxic megacolon, and a higher risk of dysplasia and colorectal cancer. Proper management is important to manage symptoms and prevent potential complications. The first biologic therapy was approved for the treatment of UC in 2005 with quite a few more advanced therapies approved over the last 20 years. 

In this Guidelines Side-by-Side, we have compared the latest clinical practice guidelines, from the American Gastroenterology Association (AGA) and the American College of Gastroenterology (ACG) on ulcerative colitis, focusing on pharmacologic treatment of moderate to severe UC. The recommendations made are meant to guide clinical practice, taking into consideration the unique desires and needs of individual patients. 

Guidelines for Comparison

Key Takeaways

• The guideline from the AGA is a living guideline reviewed and updated every 6 months. The most current update focused on pharmacologic management of moderate to severe UC. Fourteen recommendations were made intended for patients with moderate to severe UC being managed as an outpatient. Advanced therapies for initiation and maintenance of remission, medications for patients naive to advanced therapies, and medications for patients who have been exposed to advanced therapies were discussed. This article only reviewed the recommendations for initiation and maintenance of remission.

• In contrast the ACG guideline was more all-encompassing with 54 recommendations and 57 key concept statements. Recommendations for diagnosis, assessment, monitoring, prognosis, management of mild to moderate UC, management of moderate to severe UC, and management of hospitalized patients with acute severe UC were all included. This article covers the management of patients with moderate to severe UC.

• The ACG made recommendations for the use of oral budesonide and oral systemic corticosteroids for induction of remission, while the update from the AGA did not address these medications.

• Some areas that differed in these two guidelines include:
  • Infliximab was suggested for combination use with an immunomodulator by the AGA while the ACG also recommended combination therapy, they specifically recommended a thiopurine be used with infliximab.
  • The ACG and AGA recommended golimumab and adalimumab for induction and maintenance, but the AGA also suggested these be used in combination with an immunomodulator.
  • Vedolizumab was recommended by both societies for induction and maintenance. The ACG adds that this drug is recommended over adalimumab.
  • Filgotinib was not addressed by the ACG, but was recommended for induction and maintenance by the AGA.

• These guidelines were otherwise in agreement with the exception of some differences in the strength of the recommendation which can be viewed in the table below.

Comparison of Recommendations

This concludes our Guidelines Side-by-Side on ulcerative colitis. Don’t forget to sign up for alerts to stay informed on the latest published guidelines and articles.

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