Overview
Ulcerative colitis (UC) is a chronic inflammatory bowel disease characterized by inflammation and ulceration of the colon. Moderate UC involves significant symptoms and inflammation that impact a patient's quality of life and require effective treatment to achieve and maintain remission 12.Diagnosis
Diagnosis is based on clinical presentation, endoscopic findings, and histology.
Adapted Mayo score of 5-9 with an endoscopic subscore of 2 or 3 indicates moderately to severely active disease 2.Management
Advanced Therapies:
* Infliximab, golimumab, vedolizumab, tofacitinib, upadacitinib, ustekinumab, ozanimod, etrasimod, risankizumab, and guselkumab are recommended for moderate-to-severe UC 1.
* Adalimumab, filgotinib, and mirikizumab are suggested 1.
Treatment Naïve to Advanced Therapies:
* Consider higher-efficacy medications (e.g., infliximab, vedolizumab, ozanimod, etrasimod, upadacitinib, risankizumab, guselkumab) or intermediate-efficacy medications (e.g., golimumab, ustekinumab, tofacitinib, filgotinib, mirikizumab) over lower-efficacy medications (e.g., adalimumab) 1.
Previously Exposed to Advanced Therapies:
* Consider higher-efficacy medications (e.g., tofacitinib, upadacitinib) particularly in patients previously treated with TNF-α antagonists 1.
Upadacitinib:
* Oral selective Janus kinase 1 inhibitor studied for induction (45 mg once daily for 8 weeks) and maintenance (15 mg or 30 mg once daily for 52 weeks) in patients with moderate-to-severe UC who achieved clinical response during induction 2.Key Recommendations
In adult outpatients with moderate-to-severe UC, use infliximab, golimumab, vedolizumab, tofacitinib, upadacitinib, ustekinumab, ozanimod, etrasimod, risankizumab, and guselkumab over no treatment (Evidence: Strong) 1.
In patients with moderate-to-severe UC who are naïve to advanced therapies, consider a higher-efficacy medication (e.g., infliximab, vedolizumab, ozanimod, etrasimod, upadacitinib, risankizumab, guselkumab) or an intermediate-efficacy medication (e.g., golimumab, ustekinumab, tofacitinib, filgotinib, mirikizumab) rather than a lower-efficacy medication (e.g., adalimumab) (Evidence: Strong) 1.
In patients with moderate-to-severe UC who have previously been exposed to one or more advanced therapies, particularly TNF-α antagonists, consider using a higher-efficacy medication (e.g., tofacitinib, upadacitinib) (Evidence: Strong) 1.References
1 Singh S, Loftus EV, Limketkai BN, Haydek JP, Agrawal M, Scott FI et al.. AGA Living Clinical Practice Guideline on Pharmacological Management of Moderate-to-Severe Ulcerative Colitis. Gastroenterology 2024. link
2 Danese S, Vermeire S, Zhou W, Pangan AL, Siffledeen J, Greenbloom S et al.. Upadacitinib as induction and maintenance therapy for moderately to severely active ulcerative colitis: results from three phase 3, multicentre, double-blind, randomised trials. Lancet (London, England) 2022. link00581-5)