Maintenance therapy in ulcerative colitis

Maintenance therapy

  • If not already performed, plan index colonoscopy once disease in remission to classify disease

  • Define schedule for surveillance

  • Consider 5-ASA as chemoprevention against cancer

  • Ensure vaccines updated

  • Provide patient education

  • Provide contact details in case of disease flare

Joint treatment plan

ECCO statement 12B (UC 2017)

Long-term maintenance treatment is recommended for almost all patients [EL1]. Intermittent therapy is acceptable insome patients with proctitis [EL3]

ECCO statement 12C (UC 2017)

Choice of maintenance treatment is determined by disease extent [EL1], disease course [frequency and intensity of flares] [EL5], failure and adverse events of previous maintenance treatment [EL5], severity of the most recent flare [EL5], treatment used for inducing remission during the most recent flare [EL5], safety of maintenance treatment [EL1], and cancer prevention [EL2]

ECCO statement 12D (UC 2017)

Options for a stepwise escalation of maintenance therapy include dose escalation of oral/rectal aminosalicylates [EL1], the addition of thiopurines [EL2], and anti-TNF therapy or vedolizumab [EL1]

Further information

  • More than 50% of patients relapse within 1 year of a flare
  • Risk factors for relapse:
    • poor compliance maintenance therapy (adherence to mesalazine a major factor with OR 5.5)
    • frequent previous relapses
    • extra-intestinal manifestations
    • low fibre diet
    • younger age
    • basal plasmacytosis within rectal biopsy
    • polymorphs in rectal mucosa
    • stress or major stressful event
    • being single
Remission induced by…

5-ASA or
index steroid course

Steroid-dependent

Anti-TNF or vedolizumab

Repeat steroid course, or ciclosporin

Thiopurine

ECCO statement 12E (UC 2017)

Mesalamine compounds are the first-line maintenance treatment in patients responding to mesalamine or steroids [oral or rectal] [EL1]. Rectal mesalamine is first-line maintenance in proctitis and an alternative in left-sided colitis [EL1]. A combination of oral and rectal mesalamine may be used as second-line maintenance treatment [EL1]

ECCO statement 12F (UC 2017)

The effective dose of oral mesalamine to maintain remission is 2 g/day [EL1]. For rectal treatment, 3 g/week in divided doses may be sufficient. Once-daily administration of mesalamine is the preferred dosing regimen [EL2]. Although sulphasalazine is equally or slightly more effective [EL1], oral mesalamine preparations are preferred to reduce toxicity. All preparations of oral mesalamine are effective [EL1]

ECCO statement 12K (UC 2017)

Mesalamine maintenance treatment should be continued long-term [EL3]; this may reduce the risk of colon cancer [EL3]

Further information

  • Oral 5-ASA reduces relapse by ≈ 50% (95% CI 0.36-0.62) with NNT of 6

  • Similar magnitude but better response seen using topical 5-ASA for distal UC

  • Combined oral and topical therapy superior to either alone

  • See 5-ASA intervention section for further information

5-ASA maintenance

ECCO statement 11I (UC 2017)

Patients with steroid-dependent disease should be treated with a thiopurine [EL2], anti-TNF [EL1] [preferably combined with thiopurines, at least for infliximab [EL2]], vedolizumab [EL2], or methotrexate [EL2]. In case of treatment failure, second-line medical therapy with an alternative anti-TNF [EL4], vedolizumab [EL2], or colectomy [EL5] should be considered

ECCO statement 12A (UC 2017)

The goal of maintenance therapy in ulcerative colitis is to maintain steroid-free remission, defined clinically [EL1] and endoscopically [EL2]

Further information

  • Following first course of steroids without other subsequent therapies, 50% have prolonged response, 25% remain steroid dependent and 25% undergo colectomy over the following year

  • Steroid use beyond 3 months deemed chronic / prolonged

  • Thiopurines required if steroid dependency. 50% will be in steroid-free remission at 6/12 months. Methotrexate can be considered if thiopurine intolerant / refractory.

Avoid chronic steroid therapy

ECCO statement 12I (UC 2017)

Anti-TNF or vedolizumab may be used as first-line biological therapy. Vedolizumab is effective in patients failing anti-TNF [EL2]. In patients responding to vedolizumab, maintenance therapy with vedolizumab is appropriate [EL2]

Further information

  • Maintenance anti-TNF indicated if relapse occurred despite optimal thiopurine therapy. Newer agents can also be considered, e.g. Vedolizumab.

Consider maintenance anti-TNF or vedolizumab

ECCO Statement OI 5B (UC)

No vaccines are available for prevention of P. jiroveci pneumonia. For patients on triple immunomodulators with one of these being either a calcineurin inhibitor or anti-TNF therapy, standard prophylaxis with co-trimoxazole is recommended if tolerated [EL4]. For those on double immunomodulators, prophylactic co-trimoxazole should be considered especially if one of these is a calcineurin inhibitor [EL 4].

Further information

  • Steroids can be tapered over total of ≈ 8 weeks

  • Thiopurines indicated following IV steroids or ciclosporin , or with 2nd steroid course in any year. Usually introduced after 1 week - 1 month. Thiopurines reduce colectomy rates

  • Most experts stop ciclosporin after ≈3 months. One study suggests that oral ciclosporin after IV therapy is not required in patients “bridging” to azathioprine

  • Provide Septrin prophylaxis in patients receiving triple immune suppression and consider in those on dual immunosupression

  • See ciclosporin intervention section for further information

Taper steroids and start thiopurines +/- anti-TNF

  • Thiopurines have slow-onset of action and mainly used to maintain remission induced by another agent

  • Therapy should be optimized based on patient weight and blood monitoring

Optimise thiopurine therapy

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