The AMERICAN Gastroenterological Association (AGA) has released a new set of guidelines to assist healthcare providers in the pharmacological management of moderate-to-severe ulcerative colitis (UC).
The recommendations address the use of advanced therapies in adult outpatients with moderate-to-severe UC, prioritising treatments proven to be effective in achieving remission and maintaining long-term control. A key focus of the guidelines is on the use of advanced medications such as infliximab, vedolizumab, upadacitinib, ustekinumab, ozanimod, and risankizumab, among others. These therapies are recommended for patients new to advanced treatments, with the AGA emphasising the selection of higher-efficacy drugs over less effective alternatives, such as adalimumab.
For patients who have previously been treated with advanced therapies, particularly those targeting TNF-α, the guidelines again suggest prioritising medications with higher efficacy, including upadacitinib and ustekinumab. Intermediate-efficacy options like filgotinib and mirikizumab are also viable, but lower-efficacy options such as adalimumab are generally less favoured for this group.
The AGA also provides recommendations on combination therapy, advising the use of TNF antagonists like infliximab, golimumab, and adalimumab in conjunction with immunomodulators, as opposed to monotherapy. However, the panel does not make a recommendation for or against combining non-TNF biologics with immunomodulators, reflecting uncertainty in the evidence.
In terms of maintenance and therapy withdrawal, the guidelines suggest that patients who have achieved corticosteroid-free remission for at least 6 months on a combination of TNF antagonists and immunomodulators should continue their TNF antagonist therapy. No clear guidance is given on discontinuing immunomodulators in these patients.
The AGA recommends discontinuing 5-aminosalicylates in patients who have escalated to immunomodulators or advanced therapies, signalling a shift away from these medications once more robust treatments are initiated. Thiopurine monotherapy is advised against for inducing remission, though it may still play a role in maintaining remission for certain patients. Methotrexate monotherapy, by contrast, is not recommended for either induction or maintenance.
The guidelines emphasise early adoption of advanced therapies for patients with moderate-to-severe UC, moving away from the traditional “step-up” approach where treatment intensifies only after less potent therapies fail. Instead, the AGA advocates for a more proactive strategy to improve outcomes and minimise disease complications.
In addition to these clinical recommendations, the panel identifies critical areas where further research is needed, including the comparative efficacy of combination therapies and the long-term safety profiles of emerging medications.
These comprehensive guidelines provide healthcare providers with a robust framework to navigate complex treatment decisions for UC, ensuring that patients receive timely and effective personalised care.
Reference
Singh S et al. AGA living clinical practice guideline on pharmacological management of moderate-to-severe ulcerative colitis. Gastroenterology. 2024;167(7):1307-1343.
