Introduction
Ulcerative colitis [UC] is a chronic inflammatory bowel disease [IBD] characterised by colonic inflammation extending to a variable extent from the rectum. Care of the patient with UC requires appropriate input from across the multiprofessional team. These guidelines summarise the recommended medical treatment for adults with UC.
In 2022, the European Crohn’s and Colitis Organisation [ECCO] published new guidelines on the management of UC in two papers focused on the medical and surgical management of the disease.1,2 For the 2022 UC guidelines, ECCO adopted the Grading of Recommendations Assessment, Development, and Evaluation [GRADE] approach, a systematic process for developing guidelines that addresses how to frame healthcare questions, summarise the evidence, formulate recommendations, and grade their strength and the quality of associated evidence.3 The present paper represents an update to the 2022 guidelines and focuses specifically on the medical management of UC, while a companion paper developed as part of the same process addresses optimal surgical management [ECCO Guidelines on Therapeutics in Ulcerative Colitis: Surgical Treatment].
For this iteration of the guidelines, we have introduced several new, clinically relevant questions selected by members of the guidelines group, alongside a systematic approach to reviewing and updating previous topics to incorporate new evidence and to reappraise all findings within the context of contemporary practice. We have also introduced several “practice points” to summarise evidence and provide expert recommendations in key areas where the evidence remains limited but clinical decisions are still required. In such instances, where application of the GRADE methodology may be impractical, we adopted an approach based on systematic literature review, expert discussion, and voting to reach consensus recommendations outside the formal GRADE process.
Patients living with UC can have a variable disease course.4 In this document, we discuss therapeutic approaches stratified by disease severity [mildly-to-moderately active and moderately-to-severely active disease]. Definitions of disease severity are commonly used to establish clinical trial inclusion criteria and may be based on several distinct assessment frameworks.5 It is also important to remember that these definitions capture severity at a given point in time and may not reflect the cumulative long-term burden of disease experienced by a patient.6
It is also important to consider disease extent when planning treatment in UC, as this may affect the optimal route of drug administration. This is typically defined according to disease involving the rectum only [proctitis], disease distal to the splenic flexure [left-sided or distal UC], or disease extending proximal to the splenic flexure [extensive UC].7 It should be noted that disease distribution can change4 and that proximal disease extension can be a negative prognostic marker.8