David T. Rubin, MD, on the Updated ACG Guidelines for Managing UC
The American College of Gastroenterology (ACG) has issued an updated guideline for the management of adults with ulcerative colitis (UC) that includes recommendations on considering disease prognosis, recommendations on treating the hospitalized patient, new strategies for colon cancer screening, and more.
Gastroenterology Consultant caught up with David T. Rubin, MD, professor of medicine and section chief of Gastroenterology, Hepatology, and Nutrition at the University of Chicago, and lead author of the guidelines, on what gastroenterologists need to know about the guidelines.
Gastroenterology Consultant: How have the guidelines changed since the last update in 2010?
David Rubin: These guidelines were written with the clinician in mind. We wanted to make them practical, while thinking ahead and pushing the envelope so they wouldn’t be outdated the moment they were published. The guidelines not only reflect important changes in the field of gastroenterology, but also in the way guidelines are developed by the ACG. The ACG adopted an approach of grading the strengths of recommendations based on the available literature, and a more structured, systematic way to develop these guidelines. Our colleagues will find that this is very consistent with other guidelines released by the college in recent years.
There has also been a general shift in our understanding of the goal of managing UC. More specifically, we have now moved to understanding not just that the patient should feel better and have symptomatic improvement, but we have to heal the bowel and demonstrate objective evidence that the disease is under control. Another important update to the guidelines is the multiple new treatments available. There has also been an important shift in our general discussion about disease severity.
GASTRO CON: How do the guidelines incorporate disease activity and severity in UC management?
DR: What we’ve done is separate disease activity from disease severity. Prior to the updated guidelines, what we had said about choosing maintenance therapy was that a physician chooses a treatment based on how the patient is doing at that exact moment, and if it worked, then the patient would be committed to maintenance. However, it is more beneficial to the patient when a clinician considers prognosis when choosing therapy in the maintenance phase. Now we are saying maintenance therapy should be based on prognosis as well as a patient’s current disease activity. This is an important change.
GASTRO CON: What is the role of endoscopic appearance in disease activity?
DR: Endoscopic appearance should now be used as a marker of disease activity. Surprisingly, given the fact that UC is a disease of the mucosa, the endoscopic appearance was not included in prior disease activity. Now, we’ve added endoscopic appearance as a way to incorporate this idea of healing the bowel. In addition, a surrogate of endoscopic appearance stool marker called fecal calprotectin has been added to the guideline, which many of our colleagues already use. It is important that the level of evidence has reached a point where we can embrace calprotectin. It will help payers and providers support this approach and minimize patients’ need to have excessive endoscopy, which also supports the goal of healing the bowel.
GASTRO CON: What recommendations do you think are unique to the guidelines?
DR: There are a number of important recommendations and key statements for the treatment of the hospitalized patient with UC. There have been significant advances in the field for this important group of patients, and we want to support them. New recommendations also emphasize the importance of testing for Clostridioides [formerly Clostridium] and give guidance on how to treat it differently.
The guidelines also address treating patients to prevent venous thrombotic events. This is important because this patient population is at increased risk.
Colorectal cancer prevention in colitis, an area of debate due to the consensus statement published years ago on the use of dye spray on the colon, is also addressed in the updated guidelines. The dye spray enhances detection of precancerous changes with older scopes; however, there have been many barriers for gastroenterologists to use this. Fortunately, there have been advances in the literature that show higher-definition scopes are an alternative to dye spray. Other practical recommendations for cancer prevention in this population are also included in the guidelines.
Read the updated guideline here.
Rubin DT, Ananthakrishnan AN, Siegel CA, Sauer BG, Long MD. ACG clinical guideline: ulcerative colitis in adults. Am J Gastroenterol. 2019;114(3):384-413. doi:10.14309/ajg.0000000000000152.