Ulcerative colitis (UC) impacts nearly 2 million individuals in the United States. This chronic inflammatory bowel disease typically emerges in early adulthood and follows a pattern of relapsing and remitting symptoms. Unfortunately, up to 20% of patients may eventually require colectomy, and 33% may need hospitalization for disease management.
Effectively controlling inflammatory activity is essential to reducing the risk of complications associated with UC. One crucial aspect of achieving this control is taking an informed approach when selecting therapy, whether it is for initial treatment or subsequent interventions. By carefully considering the best course of action, healthcare providers can help patients manage their condition more effectively and improve their quality of life.
Given the importance of pharmacological management in patients with moderate-to-severe UC, the American Gastroenterological Association (AGA) has recently updated its clinical guideline on the management of moderate to severe ulcerative colitis to incorporate new research, clinical trials, and evolving treatment strategies. In this article, we will compare the 2024 and 2020 versions of the AGA guidelines for UC, highlighting key differences in recommendations and the integration of new therapies. While we will not delve into every detail, we recommend reviewing the full guidelines provided below for a more comprehensive understanding.
Guidelines Referenced
- Pharmacological Management of Moderate to Severe Ulcerative Colitis
- Published: November 2024
- Management of Moderate to Severe Ulcerative Colitis
- Published: April 2020
Major Changes and Key Takeaways (2020 vs 2024)
| 2020 Guideline | 2024 Guideline | |
|---|---|---|
| Pharmacological Treatments | infliximab, adalimumab, golimumab, vedolizumab,tofacitinib or ustekinumab over no treatment. | infliximab, golimumab, vedolizumab, tofacitinib, upadacitinib, ustekinumab, ozanimod, etrasimod, risankizumab and guselkumab over no treatment. |
| Steroid Use | Short-term use for flare-ups, but corticosteroids should be avoided for long-term use. | Minimize corticosteroid use—focus on steroid-free remission. Biologics introduced earlier to avoid steroid reliance. |
| Step-up Approach | Recommended step-up therapy (starting with steroids or immunosuppressants, then moving to biologics). | Start with advanced therapies and/or immunomodulators, rather than a step-up approach. |
| Immunosuppressive Therapy | Thiopurines (azathioprine) and methotrexate for maintenance after biologic induction. | Immunosuppressive therapy is less emphasized; biologic monotherapy preferred. Immunosuppressives may be combined with biologics in difficult-to-treat cases. |
| JAK Inhibitors (Tofacitinib) | Tofacitinib for patients failing biologics; used in second-line therapy. | Tofacitinib remains an option for refractory cases, but newer biologics (IL-23 inhibitors) are prioritized. Concerns over the risk of adverse cardiovascular outcomes with JAK inhibitors. |
| Living Guideline | Static | Living guideline allows for rapid updates based on new evidence. |
| Patient-Centered Care | Individualized therapy based on disease severity. | Shared decision-making emphasized, considering patient preferences, treatment goals (steroid-free remission), and lifestyle factors. |
| Goal of Treatment | Goal is inducing remission and preventing flare-ups. | Goal is to achieve steroid-free remission early, with an emphasis on long-term disease control and improving quality of life. |
Key Shifts from 2020 to 2024:
- Initial Review:
- Before initiating advanced therapies, patients should receive confirmation of active inflammation based on symptoms related to ulcerative colitis, biomarkers, and/or endoscopic evaluation.
- Biologic Therapy:
- A stronger emphasis on IL-23 inhibitors and vedolizumab as first-line biologics, reflecting a shift toward targeted therapies over broader immune suppression.
- Steroid Use:
- The 2024 guidelines make a clearer push to achieve steroid-free remission, reflecting the growing concern over long-term steroid use.
- Early Biologic Use:
- The 2024 guidelines focus on early biologic intervention to avoid corticosteroid dependency, rather than relying on a step-up approach from immunosuppressants to biologics.
- Immunosuppressive Use:
- Immunosuppressives like thiopurines are less emphasized in the 2024 version, with a greater focus on biologics.
- Patient-Centered Approach:
- More robust shared decision-making is recommended, with discussions about treatment goals, side effects, and patient preferences becoming more integral to the management strategy.
- Efficacy Categorization:
- The 2024 version has medications grouped into "efficacy buckets" based on likelihood of inducing remission.
- Vaccinations:
- In order to reduce the risk of serious infections when using immunosuppressive therapies, it is recommended to consider vaccination against influenza, pneumococcal pneumonia, and herpes zoster. This is especially important before starting treatment with S1P receptor modulators or JAK inhibitors.
- Living Guideline:
- 2024 guidelines are designed as a living document, allowing for regular updates to incorporate the latest evidence and advancements in treatment options.
The 2024 AGA guidelines reflect the growing trend of personalized and biologic-focused therapy, with an emphasis on early intervention with biologics and efforts to achieve steroid-free remission. This shift is largely driven by advances in biologic therapies, including IL-23 inhibitors, and more evidence supporting the safety and efficacy of therapies like vedolizumab and tofacitinib. While the 2020 guidelines focused more on traditional therapies like corticosteroids and thiopurines, the 2024 version marks a clear transition to biologic and targeted therapies, with a stronger focus on patient-centered care and shared decision-making.
We are grateful for your ongoing interest, and we encourage you to stay informed about upcoming segments in our series. We value your feedback and would like to hear your suggestions for future topics to be covered in our guideline series. Please feel free to contact us with any ideas or questions you may have.
Sign up for alerts and stay informed on the latest published guidelines and articles.
Copyright © 2024 Guideline Central, All rights reserved.