Ulcerative colitis: management

National Institute for Health and Care Excellence


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  • This Guidelines summary includes the key priorities for implementation, and sections on Pregnant women and Monitoring from the full guideline. Please refer to the full guideline for the complete list of recommendations

Key priorities for implementation

  • The following recommendations have been identified as priorities for implementation

Patient information and support

  • Discuss the disease and associated symptoms, treatment options, and monitoring:
    • with the person with ulcerative colitis, and their family members or carers as appropriate and
    • within the multidisciplinary team (the composition of which should be appropriate for the age of the person) at every opportunity
  • Apply the principles in Patient experience in adult NHS services (NICE clinical guideline 138)

Inducing remission: step 1 therapy for mild to moderate ulcerative colitis

  • To induce remission in people with a mild to moderate first presentation or inflammatory exacerbation of proctitis or proctosigmoiditis:
    • offer a topical aminosalicylate* alone (suppository or enema, taking into account the person’s preferences) or
    • consider adding an oral aminosalicylate to a topical aminosalicylate or
    • consider an oral aminosalicylate alone, taking into account the person’s preferences, and explaining that this is not as effective as a topical aminosalicylate alone or combined treatment
  • To induce remission in adults with a mild to moderate first presentation, or inflammatory exacerbation of left-sided, or extensive ulcerative colitis:
    • offer a high induction dose of an oral aminosalicylate
    • consider adding a topical aminosalicylate or oral beclometasone dipropionate, taking into account the person’s preferences
  • To induce remission in children and young people with a mild to moderate first presentation, or inflammatory exacerbation of left-sided, or extensive ulcerative colitis:
    • offer an oral aminosalicylate§
    • consider adding a topical aminosalicylate,* or oral beclometasone dipropionate,ı taking into account the person’s preferences (and those of their parents or carers as appropriate)

Inducing remission: step 2 therapy for acute severe ulcerative colitis

  • Consider adding intravenous ciclosporin to intravenous corticosteroids, or consider surgery for people:
    • who have little or no improvement within 72 hours of starting intravenous corticosteroids or
    • whose symptoms worsen at any time despite corticosteroid treatment
  • Take into account the person’s preferences when choosing treatment

Monitoring treatment

  • Ensure that there are documented local safety monitoring policies and procedures (including audit) for adults, children, and young people receiving treatment that needs monitoring (aminosalicylates, tacrolimus, ciclosporin, infliximab, azathioprine, and mercaptopurine). Nominate a member of staff to act on abnormal results and communicate with GPs and people with ulcerative colitis (and/or their parents or carers as appropriate)

Assessing likelihood of needing surgery

  • Assess and document on admission, and then daily, the likelihood of needing surgery for people admitted to hospital with acute severe ulcerative colitis

Information about treatment options for people who are considering surgery

  • For people with ulcerative colitis who are considering surgery, ensure that a specialist (such as a gastroenterologist or a nurse specialist) gives the person (and their family members or carers as appropriate) information about all available treatment options, and discusses this with them. Information should include the benefits and risks of the different treatments and the potential consequences of no treatment
  • After surgery, ensure that a specialist who is knowledgeable about stomas (such as a stoma nurse or a colorectal surgeon) gives the person (and their family members or carers as appropriate) information about managing the effects on bowel function. This should be specific to the type of surgery performed (ileostomy or ileoanal pouch) and could include the following:
    • strategies to deal with the impact on their physical, psychological, and social wellbeing
    • where to go for help if symptoms occur
    • sources of support and advice

Maintaining remission

  • Consider a once-daily dosing regimen for oral aminosalicylates** when used for maintaining remission. Take into account the person’s preferences, and explain that once-daily dosing can be more effective, but may result in more side-effects

Pregnant women

  • When caring for a pregnant woman with ulcerative colitis:
    • ensure effective communication and information-sharing across specialties (for example, primary care, obstetrics and gynaecology, and gastroenterology)
    • give her information about the potential risks and benefits of medical treatment to induce or maintain remission and of no treatment, and discuss this with her. Include information relevant to a potential admission for an acute severe inflammatory exacerbation

Monitoring

Monitoring bone health

  • Adults:
    • for recommendations on assessing the risk of fragility fracture in adults, refer to Osteoporosis: assessing the risk of fragility fracture (NICE clinical guideline 146)
  • Children and young people:
    • consider monitoring bone health in children and young people with ulcerative colitis in the following circumstances:
      • during chronic active disease
      • after treatment with systemic corticosteroids
      • after recurrent active disease

Monitoring growth and pubertal development in children and young people

  • Monitor the height and body weight of children and young people with ulcerative colitis against expected values on centile charts (and/or z scores) at the following intervals according to disease activity:
    • every 3–6 months:
      • if they have an inflammatory exacerbation and are approaching or undergoing puberty or
      • if there is chronic active disease
      • if they are being treated with systemic corticosteroids
      • every 6 months during pubertal growth if the disease is inactive
      • every 12 months if none of the criteria above are met
  • Monitor pubertal development in young people with ulcerative colitis using the principles of Tanner staging, by asking screening questions and/or carrying out a formal examination
  • Consider referral to a secondary care paediatrician for pubertal assessment and investigation of the underlying cause if a young person with ulcerative colitis:
    • has slow pubertal progress or
    • has not developed pubertal features appropriate for their age
  • Monitoring of growth and pubertal development:
    • can be done in a range of locations (for example, at routine appointments, acute admissions, or urgent appointments in primary care, community services, or secondary care)
    • should be carried out by appropriately trained healthcare professionals as part of the overall clinical assessment (including disease activity) to help inform the need for timely investigation, referral and/or interventions, particularly during pubertal growth
    • if the young person prefers self-assessment for monitoring pubertal development, this should be facilitated where possible and they should be instructed on how to do this
  • Ensure that relevant information about monitoring of growth and pubertal development and about disease activity is shared across services (for example, community, primary, secondary and specialist services). Apply the principles in Patient experience in adult NHS services (NICE clinical guideline 138) in relation to continuity of care

*  At the time of publication (June 2013), some topical aminosalicylates did not have a UK marketing authorisation for this indication in children and young people. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Good practice in prescribing and managing medicines and devices for further information
  At the time of publication (June 2013), some oral aminosalicylates did not have a UK marketing authorisation for this indication in children and young people. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Good practice in prescribing and managing medicines and devices for further information
  At the time of publication (June 2013), beclometasone dipropionate only has a UK marketing authorisation ‘as add-on therapy to 5-ASA containing drugs in patients who are non-responders to 5-ASA therapy in active phase’. For use outside these licensed indications, the prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Good practice in prescribing and managing medicines and devices for further information
§  Dosing requirements for children should be calculated by body weight, as described in the BNF
ı  At the time of publication (June 2013), beclometasone dipropionate did not have a UK marketing authorisation for this indication in children and young people. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Good practice in prescribing and managing medicines and devices for further information
  At the time of publication (June 2013), ciclosporin did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Good practice in prescribing and managing medicines and devices for further information
**   At the time of publication (June 2013), not all oral aminosalicylates had a UK marketing authorisation for once-daily dosing. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Good practice in prescribing and managing medicines and devices for further information

References

full guideline available from…
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
www.nice.org.uk/guidance/CG166

National Institute for Health and Care Excellence. Ulcerative colitis: management. June 2013
First included: June 2013.


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