Ulcerative Colitis: Management

Overview

This NICE guideline summary covers the management of ulcerative colitis in children, young people and adults. It aims to help professionals to provide consistent high-quality care and it highlights the importance of advice and support for people with ulcerative colitis.

This guideline replaces CG166. This guideline is the basis of QS81.

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 the NICE guideline on patient experience in adult NHS services
• Discuss the possible nature, frequency and severity of side effects of drug treatment for ulcerative colitis with the person, and their family members or carers (as appropriate). Refer to the NICE guideline on medicines adherence
• Give the person, and their family members or carers (as appropriate) information about their risk of developing colorectal cancer and about colonoscopic surveillance, in line with the NICE guidelines on:
  • colorectal cancer prevention: colonoscopic surveillance in adults with ulcerative colitis, Crohn’s disease or adenomas
  • suspected cancer: recognition and referral.

Inducing Remission in People with Ulcerative Colitis

Treating Mild-to-Moderate Ulcerative Colitis

Proctitis

• To induce remission in people with a mild-to-moderate first presentation or inflammatory exacerbation of proctitis, offer a topical aminosalicylate^[A] as first-line treatment
• If remission is not achieved within 4 weeks, consider adding an oral aminosalicylate^[B]
• If further treatment is needed, consider adding a time-limited course of a topical or an oral corticosteroid^[C]
• For people who decline a topical aminosalicylate:
  • consider an oral aminosalicylate as first-line treatment, and explain that this is not as effective as a topical aminosalicylate
  • if remission is not achieved within 4 weeks, consider adding a time-limited course of a topical or an oral corticosteroid^[C]
• For people who cannot tolerate aminosalicylates, consider a time-limited course of a topical or an oral corticosteroid.

Proctosigmoiditis and Left-sided Ulcerative Colitis

• To induce remission in people with a mild-to-moderate first presentation or inflammatory exacerbation of proctosigmoiditis or left-sided ulcerative colitis, offer a topical aminosalicylate as first-line treatment
• If remission is not achieved within 4 weeks, consider:
  • adding a high-dose oral aminosalicylate to the topical aminosalicylate or
  • switching to a high-dose oral aminosalicylate and a time-limited course of a topical corticosteroid
• If further treatment is needed, stop topical treatments and offer an oral aminosalicylate and a time-limited course of an oral corticosteroid
• For people who decline any topical treatment:
  • consider a high-dose oral aminosalicylate alone, and explain that this is not as effective as a topical aminosalicylate
  • if remission is not achieved within 4 weeks, offer a time-limited course of an oral corticosteroid in addition to the high-dose aminosalicylate
• For people who cannot tolerate aminosalicylates, consider a time-limited course of a topical or an oral corticosteroid.

Extensive Disease

• To induce remission in people with a mild-to-moderate first presentation or inflammatory exacerbation of extensive ulcerative colitis, offer a topical aminosalicylate and a high-dose oral aminosalicylate as first-line treatment
• If remission is not achieved within 4 weeks, stop the topical aminosalicylate and offer a high-dose oral aminosalicylate with a time-limited course of an oral corticosteroid
• For people who cannot tolerate aminosalicylates, consider a time-limited course of an oral corticosteroid.

Biologics and Janus Kinase Inhibitors for Moderately to Severely Active Ulcerative Colitis: All Extents of Disease

• For guidance on biologics and Janus kinase inhibitors for treating moderately to severely active ulcerative colitis, see the NICE technology appraisal guidance on:
  • infliximab, adalimumab and golimumab for moderately to severely active ulcerative colitis
  • vedolizumab for treating moderately to severely active ulcerative colitis
  • tofacitinib for moderately to severely active ulcerative colitis
    
    See the full guideline for recommendations on treating acute severe ulcerative colitis and on treatment options for people who are considering surgery.

Maintaining Remission in People With Ulcerative Colitis

Proctitis and Proctosigmoiditis

• To maintain remission after a mild-to-moderate inflammatory exacerbation of proctitis or proctosigmoiditis, consider the following options, taking into account the person’s preferences:
  • a topical aminosalicylate^[A] alone (daily or intermittent) or
  • an oral aminosalicylate^[B] plus a topical aminosalicylate^[A] (daily or intermittent) or
  • an oral aminosalicylate^[B] alone, explaining that this may not be as effective as combined treatment or an intermittent topical aminosalicylate alone.

Left-sided and Extensive Ulcerative Colitis

• To maintain remission in adults after a mild-to-moderate inflammatory exacerbation of left-sided or extensive ulcerative colitis:
  • offer a low maintenance dose of an oral aminosalicylate
  • when deciding which oral aminosalicylate to use, take into account the person’s preferences, side effects and cost
• To maintain remission in children and young people after a mild-to-moderate inflammatory exacerbation of left-sided or extensive ulcerative colitis:
  • offer an oral aminosalicylate^[B],[D]
  • when deciding which oral aminosalicylate to use, take into account the person’s preferences (and those of their parents or carers as appropriate), side effects and cost.

All Extents of Disease

• Consider oral azathioprine^[E] or oral mercaptopurine^[E] to maintain remission:
  • after 2 or more inflammatory exacerbations in 12 months that require treatment with systemic corticosteroids or
  • if remission is not maintained by aminosalicylates
• To maintain remission after a single episode of acute severe ulcerative colitis:
  • consider oral azathioprine^[E] or oral mercaptopurine^[E]
  • consider oral aminosalicylates if azathioprine and/or mercaptopurine are contraindicated or the person cannot tolerate them.

Dosing Regimen for Oral Aminosalicylates

• Consider a once-daily dosing regimen for oral aminosalicylates^[F] 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 not having 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 the NICE guideline on osteoporosis: assessing the risk of fragility fracture.

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 to 6 months:
    • if they have an inflammatory exacerbation and are approaching or undergoing puberty or
    • if there is chronic active disease or
    • 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 allowed if 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 the NICE guideline on patient experience in adult NHS services in relation to continuity of care.

Footnotes

[A] At the time of publication (May 2019), 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 Prescribing guidance: prescribing unlicensed medicines for further information.

[B] At the time of publication (May 2019), 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 Prescribing guidance: prescribing unlicensed medicines for further information.

[C] At the time of publication (May 2019), 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’. Additionally, budesonide (oral or rectal) and prednisolone foam are not licensed in children. 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 Prescribing guidance: prescribing unlicensed medicines for further information.

[D] Dosing requirements for children should be calculated by body weight, as described in the BNF.

[E] Although use is common in UK clinical practice, at the time of publication (May 2019) not all brands of azathioprine and mercaptopurine had 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 Prescribing guidance: prescribing unlicensed medicines for further information.

[F] At the time of publication (May 2019), 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 Prescribing guidance: prescribing unlicensed medicines for further information.