A group of Canadian experts recently published a set of guidelines aimed at improving treatment of Ulcerative Colitis (UC) for patients who are not hospitalized and are affected by mild to severe forms of the condition. The guidelines were developed in order to help physicians put the latest therapeutic options to best use in a clinical setting.
The consensus guidelines were released by The Toronto Ulcerative Colitis Consensus Group (published in Gastroenterology, April 28th, 2015), as a result of a thorough literature review completed in June 2014. After a modified Delphi discussion, 34 clauses focusing on current therapeutic options for UC, including administration of 5-aminosalicylate, corticosteroids, immunosuppressants, anti-tumor necrosis factor agents and other therapies (Entyvio [vedolizumab, Takeda Pharmaceuticals], fecal microbiota transplantation and probiotics) was published.
A systematic therapeutic regime for the medical management of UC was also released by the group, with its ultimate goal being “complete remission, including both symptomatic and endoscopic remission, with timely assessments of response and remission being a key factor in achieving this goal.” The researchers state that continued therapy with the same agents used from the beginning of treatment in UC patients, with the exception of corticosteroids, should be sufficient in maintaining remission, according to their guidelines.
Commenting on this, the authors noted, “Previous Canadian recommendations have addressed severe UC in the hospitalized patient, and these guidelines present recommendations for the non-hospitalized patient with mild-to-severe active UC. These guidelines should help to optimize the use and proper positioning of existing medical therapies and, thus, improve outcomes in patients with UC.”
This new set of rules has also faced its fair share of criticism. According to one publication by Ashwin N. Ananthakrishnan, MD, MBBS, MPH, from Massachusetts General Hospital and Harvard Medical School, and Sunanda V. Kane, MD, from Mayo Clinic in Rochester, Minnesota, the present set of guidelines diverge from its predecessor on two basic points:
- They relegate immunomodulators to a secondary role “to be used either in combination with biologics and in those who achieve symptomatic remission on oral corticosteroids, recommending against their use as monotherapy in those with steroid-dependent disease.”
- They emphasize combination immunomodulator-biologic therapy when using anti-TNF agents due to lower rates of antibody formation and subsequent improved response.
A few more aspects of the guidelines that researchers believe additional attention include optimal duration of combination therapy along with biologics, the time and safety related to withdrawal of immunomodulators from combination therapy involving corticosteroid-free remission, mucosal healing, optimal methods for patient monitoring, characterization of risks at different aspects of treatment, prognostic biomarkers, individual treatment algorithms, therapeutic drug monitoring and alternatives to endoscopic assessment of disease control.