Moderately to Severely Active Ulcerative Colitis When Corticosteroids Have Not Achieved Remission
Clinical scenario
This protocol applies to patients with moderately to severely active ulcerative colitis of any extent who have not met defined remission goals on initial corticosteroid therapy and require escalation.
Previous treatment — insufficient response
The preceding line used oral budesonide MMX (in moderately active disease) or oral systemic corticosteroids — prednisone — (in severely active disease) to induce remission. Escalation to this protocol is indicated when the following goals were not met within 8 weeks:
- Absence of rectal bleeding
- Normalised stool frequency
- Mayo endoscopic score of 0 or 1
Next-step treatment (partial overview)
Advanced therapy for induction of remission is recommended, with options from several established therapeutic categories — including, among others, S1P receptor modulators — the complete selection and approach are in the full protocol.
Treatment goals
Efficacy is assessed at a defined time point (6–12 weeks): clinical remission with absence of rectal bleeding, normalised stool frequency, and endoscopic improvement (Mayo endoscopic score 0 or 1).
References
DOI: 10.14309/ajg.0000000000003463
- In patients with moderately to severely active UC of any extent, we recommend oral systemic corticosteroids to induce remission.
- In patients with moderately to severely active UC, we recommend sphingosine-1-phosphate (S1P) receptor modulators, ozanimod and etrasimod, for induction of remission.
- In patients with moderately to severely active UC, we recommend the interleukin (IL)-12/23p40 antibody ustekinumab for induction of remission.
- In patients with moderately to severely active UC, we recommend the IL23p19 inhibitor guselkumab, mirikizumab, or risankizumab for induction of remission.
- In patients with moderately to severely active UC, we recommend vedolizumab for induction of remission.
- In patients with moderately to severely active UC, we recommend anti-tumor necrosis factor (TNF) therapy using infliximab for induction of remission.
- In patients with moderately to severely active UC, we recommend anti-TNF therapy using adalimumab or golimumab for induction of remission.
- In patients with moderately to severely active UC, we recommend the Janus kinase (JAK) inhibitor tofacitinib for induction of remission.
- In patients with moderately to severely active UC, we recommend the JAK inhibitor upadacitinib for induction of remission.
- When infliximab is used as induction therapy for patients with moderately to severely active UC, we recommend combination therapy with a thiopurine.
- Any treatment selected and administered to a patient with UC should be assessed at a defined time point (6–12 weeks) to confirm its efficacy and safety, and given risk of losing response to therapy over time, a disease monitoring strategy should be incorporated, with the intention of identifying secondary nonresponse (loss of response) early and to allow subsequent adjustment in treatment to prevent complications and additional morbidity.
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