maintenance therapy in UC

Last edited 07/2019

Ulcerative colitis:

• in UC the objective of maintenance therapy should be to maintain steroid free remission (clinically and endoscopically defined) (1)
• medications used for maintenance therapy include
• aminosalicylate (5-ASA) – first line drugs used in patients responding to 5-ASA or steroids (oral or rectal)
• thiopurines – used in patients who experience relapses or are intolerant to 5-ASA, patients who are steroid dependent or patients responding to ciclosporin for induction of remission
• infliximab – used in patients responding to infliximab
• probiotics (1)
• good evidence in ulcerative colitis that aminosalicylates are effective in the prevention of relapses
• also some evidence that the use of aminosalicylates may lead to a reduction in risk of colorectal cancer (1)

NICE suggest (2):

Pharmacological management - maintaining remission

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 aminosalicylateU1 alone (daily or intermittent), OR
    
    
  • an oral aminosalicylateU2 plus a topical aminosalicylateU1 (daily or intermittent), OR ,
    
    
  • an oral aminosalicylateU2 alone, explaining that this may not be as effective as combined treatment or an intermittent topical aminosalicylate alone

   

Left-sided and extensive UC

• to maintain remission in adults after a mild-to-moderate inflammatory exacerbation of left-sided or extensive UC:
  • a low maintenance dose of an oral aminosalicylate should be offered,
  • 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 UC:
  • an oral aminosalicylate U2, U5 should be offered
  • 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 U6 or oral mercaptopurine U6 to maintain remission:
  • after >=2 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 UC:
  • consider oral azathioprineU6 or oral mercaptopurineU6
  • 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 U7 when used for maintaining remission
  • take into account the person' preferences, and explain that once-daily dosing can be more effective, but may result in more side effects.

Notes:

• Unlicensed prescribing
  • U1 - some topical aminosalicylates are not licensed for this indication in children and young people.
  • U2 - some oral aminosalicylates are not licensed for this indication in children and young people.
  • U3 - 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.
  • U4 - ciclosporin is not licensed for this indication
  • U5 - dosing requirements for children should be calculated by body weight, as described in the BNF
  • U6 - although use is common in UK clinical practice, not all brands of azathioprine and mercaptopurine are licensed for this indication
  • U7 - at the time of publication, not all oral aminosalicylates are licensed 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

Reference:

• (1) Dignass A et al. The second European evidence-based consensus on the diagnosis and management of Crohn's disease: Current management. Journal of Crohn's and Colitis 2010; 4:28-62
• (2) NICE (May 2019). Ulcerative colitis Management in adults, children and young people