Clinical practice guidelines for the medical management of nonhospitalized ulcerative colitis: the Toronto consensus.
OBJECTIVE
The medical management of ulcerative colitis (UC) has improved through the development of new therapies and novel approaches that optimize existing drugs. Previous Canadian consensus guidelines addressed the management of severe UC in the hospitalized patient. We now present consensus guidelines for the treatment of ambulatory patients with mild to severe active UC.


METHODS
A systematic literature search identified studies on the management of UC. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Statements were developed through an iterative online platform and then finalized and voted on by a working group of specialists.


RESULTS
The participants concluded that the goal of therapy is complete remission, defined as both symptomatic and endoscopic remission without corticosteroid therapy. The consensus includes 34 statements focused on 5 main drug classes: 5-aminosalicylate (5-ASA), corticosteroids, immunosuppressants, anti-tumor necrosis factor (TNF) therapies, and other therapies. Oral and rectal 5-ASA are recommended first-line therapy for mild to moderate UC, with corticosteroid therapy for those who fail to achieve remission. Patients with moderate to severe UC should undergo a course of oral corticosteroid therapy, with transition to 5-ASA, thiopurine, anti-TNF (with or without thiopurine or methotrexate), or vedolizumab maintenance therapy in those who successfully achieve symptomatic remission. For patients with corticosteroid-resistant/dependent UC, anti-TNF or vedolizumab therapy is recommended. Timely assessments of response and remission are critical to ensuring optimal outcomes.


CONCLUSIONS
Optimal management of UC requires careful patient assessment, evidence-based use of existing therapies, and thorough assessment to define treatment success.
Division of Gastroenterology, Department of Medicine, St Paul's Hospital, Vancouver, British Columbia. Electronic address: brian_bressler@hotmail.com.
Brian
B
Bressler
Department of Medicine, McMaster University, Hamilton, Ontario.
John K
JK
Marshall
IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba.
Charles N
CN
Bernstein
Department of Medicine, McGill University Health Centre, Montreal, Quebec.
Alain
A
Bitton
Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan.
Jennifer
J
Jones
Department of Medicine, McMaster University, Hamilton, Ontario.
Grigorios I
GI
Leontiadis
Department of Medicine, University of Calgary, Calgary, Alberta.
Remo
R
Panaccione
Department of Medicine, University of Toronto, Toronto, Ontario.
A Hillary
AH
Steinhart
Department of Medicine, McMaster University, Hamilton, Ontario.
Francis
F
Tse
Robarts Research Institute, Western University, London, Ontario, Canada.
Brian
B
Feagan
D000553:Ambulatory Care / Q000592:standards*; D000893:Anti-Inflammatory Agents / Q000009:adverse effects / Q000627:therapeutic use*; D003093:Colitis, Ulcerative / Q000175:diagnosis / Q000188:drug therapy*; D032921:Consensus; D004359:Drug Therapy, Combination; D019317:Evidence-Based Medicine / Q000592:standards; D005762:Gastroenterology / Q000592:standards*; D005765:Gastrointestinal Agents / Q000009:adverse effects / Q000627:therapeutic use*; D006801:Humans; D012074:Remission Induction; D012720:Severity of Illness Index; D016896:Treatment Outcome
D000893:Anti-Inflammatory Agents; D005765:Gastrointestinal Agents
5-Aminosalicylate; Anti–Tumor Necrosis Factor; Corticosteroid; Probiotics; Thiopurine; Ulcerative Colitis; Vedolizumab