AGA Clinical Practice Guidelines on the Management of Moderate to Severe Ulcerative Colitis

Feuerstein, Joseph D.; Isaacs, Kim L.; Schneider, Yecheskel; Siddique, Shazia Mehmood; Falck‐Ytter, Yngve; Singh, Siddharth; Chachu, Karen A.; Day, Lukejohn W.; Lebwohl, Benjamin; Muniraj, Thiruvengadam; Patel, Amit; Peery, Anne F.; Shah, Raj; Sultan, Shahnaz; Singh, Harminder; Spechler, Stuart J.; Su, Grace L.; Thrift, Aaron P.; Weiss, Jennifer M.; Weizman, Adam V.; Allegretti, Jessica R.; Terdiman, Jonathan P.

doi:10.1053/j.gastro.2020.01.006

Cited by 379 publications

(352 citation statements)

References 44 publications

(70 reference statements)

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“…For the gastroenterology community (providers, patients and caregivers) this has obviously sparked particular concern for those individuals with inflammatory bowel disease (IBD). IBD is regarded as a disease of immune dysregulation, and with the exception of some limited use of diet, antibiotic and topical anti-inflammatory therapies, the vast majority of effective IBD medications for moderate to severe disease are immune suppressing/ modifying[ 8 - 10 ]. While IBD itself is not regarded to increase non-gastrointestinal (GI) infectious disease risk[ 11 ], there is ample evidence demonstrating an increased risk of non-GI, opportunistic infections associated with IBD therapies[ 12 - 16 ].…”

Section: Introductionmentioning

confidence: 99%

Review of inflammatory bowel disease and COVID-19

Sultan¹,

Mone²,

Durbin³

et al. 2020

WJG

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The first cases of a novel corona virus infection were reported in Wuhan China in December of 2019, followed by the declaration of an international pandemic by the World Health Organization in March 2020. Early reports of the virus, now known as severe acute respiratory syndrome coronavirus 2, and its clinical disease coronavirus disease 2019 (COVID-19), has shown higher rates of morbidity and mortality in the elderly and those with pre-existing medical conditions. Of particular concern is the safety of those with compromised immune systems. Inflammatory Bowel disease (IBD) is itself caused by a disordered immune response, with the most effective medical therapies being immune suppressing or modifying. As such, the risk of COVID-19, virus related outcomes, and appropriate management of IBD patients during the global pandemic is of immediate concern to gastroenterologists worldwide. There has been a rapid accumulation of clinical data and expert opinion on the topic. This review will highlight the latest source information on clinical observation/outcomes of the IBD population and provide a concise summary of the most up to date perspectives on IBD management in the age of COVID-19.

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Section: Introductionmentioning

confidence: 99%

Review of inflammatory bowel disease and COVID-19

Sultan¹,

Mone²,

Durbin³

et al. 2020

WJG

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“…No prospective studies or RCTs have evaluated the outcome of 5‐ASA withdrawal in patients treated with the Janus kinase (JAK) inhibitor tofacitinib. Indirect evidence from subgroup analysis of RCTs suggests concomitant 5‐ASA at trial entry does not affect likelihood of maintaining clinical remission after escalation to tofacitinib or anti‐TNF therapy (relative risk [RR] 0.92, 95% CI 0.78‐1.09) 48 …”

Section: ‐Asa Withdrawal In Ucmentioning

confidence: 99%

“…ECCO guidance is that the lifelong chemoprevention with 5‐ASA is justified in all patients with UC, except for those with isolated proctitis 74 . While the most recent guidelines from the American Gastroenterological Association advise that 5‐ASA may be withdrawn in all who have achieved remission with immunomodulator, biologic agents or tofacitinib, this recommendation did not factor in the potential chemopreventive benefit of 5‐ASA 48 . However, the AGA guidelines do note that sustained remission appears protective regardless of the type of therapy used.…”

Section: The Role Of 5‐asa In Crc Prevention—a Key Consideration?mentioning

confidence: 99%

“…However, this guidance predates the recent publications suggesting no benefit to concomitant 5‐ASA in patients escalated to anti‐TNF or vediolizumab 44,46 . As noted above, in the recent AGA guidelines on management of moderate‐to‐severe UC, it has been suggested that 5‐ASA therapy may be stopped in patients who have achieved remission with biologic agents and/or immunomodulators, or tofacitinib 48 . Neither European nor US guidelines recommend the use of 5‐ASA therapy in CD 6,7 …”

Section: State Of Artmentioning

confidence: 99%

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Review article: withdrawal of 5‐aminosalicylates in inflammatory bowel disease

Chapman

Gomes

Louis

et al. 2020

Aliment Pharmacol Ther

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Summary Background 5‐aminosalicylates (5‐ASA) are widely used in inflammatory bowel disease (IBD), but emerging evidence suggests that they may be safely withdrawn in significant subsets of patients. This is important to address: 5‐ASA therapy accounts for up to 25% of total healthcare costs in ulcerative colitis (UC), while almost a third of patients with Crohn's disease (CD) receive long‐term 5‐ASA despite no clear evidence of benefit. Further, rationalising medication burden may improve overall adherence and outcome. Aims To summarise the rationale for 5‐ASA withdrawal, review the current evidence in both UC and CD and consider the data surrounding colorectal cancer (CRC) prevention, guiding an evidence‐based withdrawal strategy. Methods PubMed was searched to identify relevant studies. Only papers published in English were reviewed, with priority given to randomised clinical trials and meta‐analyses. Results For patients with UC, consideration of 5‐ASA withdrawal should be made on a case‐by‐case basis, but it appears safest for those in deep remission without any of the following risk factors: younger age (<40 years), remission for less than 2 years, a history of multiple flares, extensive disease. 5‐ASA withdrawal should also be considered in patients with UC escalated to biologic therapy who have achieved remission and in all patients with CD. Although 5‐ASA therapy may have chemopreventive benefits for CRC, the cost‐benefit ratio appears significant, and this indication is not justified by evidence in those who have achieved remission and are continuing therapy with other agents, or in those in sustained remission without a history of extensive disease. Conclusions Although the majority of patients with IBD receive 5‐ASA during their disease course, safe withdrawal appears possible in many, with important implications for both health economics and patient experience. A number of unanswered questions, however, remain.

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“…Borren et al add to a growing area of research on obesity, particularly within IBD patients, in a large prospective study. Anti-TNF agents, vedolizumab, and ustekinumab all have been proven efficacious in randomized controlled trials advocating for their use over placebo in the treatment of UC and CD [7,8]. These medications may have some negative aspects, such as their cost, infection risk, or, as this study suggests, weight gain.…”

mentioning

confidence: 94%