- UC is a chronic inflammatory bowel disease with onset most frequently in young adulthood. Most patients with UC have a mild-to-moderate course characterized by periods of activity or remission. Over 90% of patients with UC are treated with 5-aminosalicylates (5-ASA) shortly after disease diagnosis, and most who achieve clinical remission with these medications continue them for maintenance of remission.
- The minority of patients with UC require immunomodulators or biologic therapies for disease control.
- For this guideline, mild-moderate UC was defined as patients with fewer than 4-6 bowel movements per day, mild-moderate rectal bleeding, absence of constitutional symptoms, low overall inflammatory burden, and absence of features suggestive of high inflammatory activity based upon Truelove and Witt’s criteria (Truelove SC, Witts LJ. Br Med J 1955;2:1041-8) and the Mayo Clinic score (https://www.mdcalc.com/mayo-score-disease-activity-index-dai-ulcerative-colitis).
- Although disease activity exists on a spectrum, patients in the mild-moderate category who have more frequent bowel movements, more prominent rectal bleeding or greater overall inflammatory burden should be considered to have moderate disease.
- The mainstay of therapy for mild-moderate UC is the 5-ASA class of medications including sulfasalazine, mesalamine and diazo-bonded 5-ASA (Table 2).
Table 1. Summary of Recommendations of AGA Clinical Guidelines Committee for the Management of Mild-to-Moderate Ulcerative Colitis
|Statement||Strength of recommendation||Quality of evidence|
|1. In patients with extensive mild-moderate ulcerative colitis, AGA recommends using either standard dose mesalamine (2-3 grams/d) or diazo-bonded 5-ASA rather than low dose mesalamine, sulfasalazine or no treatment.|
Comment – Patients already on sulfasalazine in remission or patients with prominent arthritic symptoms may reasonably choose sulfasalazine 2-4g/day if alternatives are cost-prohibitive, albeit with higher rate of intolerance
|2. In patients with extensive mild-moderate ulcerative colitis, AGA suggests adding rectal mesalamine to oral 5-ASA.||Conditional||Moderate|
|3. In patients with mild-moderate ulcerative colitis with suboptimal response to standard-dose mesalamine or diazo-bonded 5-ASA or with moderate disease activity, AGA suggests using high-dose mesalamine (>3gm/d) with rectal mesalamine.||Conditional||Moderate|
(induction of remission)
(maintenance of remission)
|4. In patients with mild-moderate UC being treated with oral mesalamine, AGA suggests using once-daily dosing rather than multiple times per day dosing.||Conditional||Moderate|
|5. In patients with mild-moderate ulcerative colitis, AGA suggests using standard-dose oral mesalamine or diazo-bonded 5-ASA, rather than budesonide MMX or controlled ileal release budesonide, for induction of remission.||Conditional||Moderate|
|6. In patients with left-sided mild-moderate ulcerative proctosigmoiditis or proctitis, AGA suggests using mesalamine enemas (or suppositories) rather than oral mesalamine.|
Comment – patients who place a higher value on convenience of oral medication administration and a lower value on effectiveness could reasonably choose oral mesalamine.
|1. In patients with mild-moderate ulcerative proctosigmoiditis who choose rectal therapy over oral therapy, AGA suggests using mesalamine enemas rather than rectal corticosteroids.|
Comment – Patients who place a higher value on avoiding difficulties associated with mesalamine enemas and a lower value on effectiveness may reasonably select rectal corticosteroid foam preparations.
|2. In patients with mild-moderate ulcerative proctitis who choose rectal therapy over oral therapy, AGA recommends using mesalamine suppositories.||Strong||Moderate|
|3. In patients with mild-moderate ulcerative proctosigmoiditis or proctitis being treated with rectal therapy who are intolerant of or refractory to mesalamine suppositories, AGA suggests using rectal corticosteroid therapy rather than no therapy for induction of remission.||Conditional||Low|
|4. In patients with mild-moderate ulcerative colitis refractory to optimized oral and rectal 5-ASA, regardless of disease extent, AGA suggests adding oral prednisone or budesonide MMX.||Conditional||Low|
|5. In patients with mild-moderate ulcerative colitis, AGA makes no recommendation for use of probiotics.||No recommendation||Knowledge gap|
|6. In patients with mild-moderate ulcerative colitis despite 5-ASA therapy, AGA makes no recommendation for use of curcumin.||No recommendation||Knowledge gap|
|7. In patients with mild-moderate ulcerative colitis without Clostridium difficile infection, AGA recommends fecal microbiota transplantation be performed only in the context of a clinical trial.||No recommendation for treatment of ulcerative colitis||Knowledge gap|
Table 2. Characteristics of available 5-aminosalicylates (5-ASA) and sulfasalazine
|Enteric or non-enteric coated tablets|
|6.75 grams of balsalazide provides approximately 2.4 grams of 5-ASA||4 grams of sulfasalazine provides approximately 1.6 grams of 5-ASA|
|Monitor renal function periodically||Monitor renal function periodically|