Division of Gastroenterology, University of California, San Diego, La Jolla, California.
Division of Gastroenterology and Center for Inflammatory Bowel Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
Gastroenterology. 2019 Feb;156(3):769-808.e29. doi: 10.1053/j.gastro.2018.12.008. Epub 2018 Dec 18.
Most patients with ulcerative colitis (UC) have mild-to-moderate disease activity, with low risk of colectomy, and are managed by primary care physicians or gastroenterologists. Optimal management of these patients decreases the risk of relapse and proximal disease extension, and may prevent disease progression, complications, and need for immunosuppressive therapy. With several medications (eg, sulfasalazine, diazo-bonded 5-aminosalicylates [ASA], mesalamines, and corticosteroids, including budesonide) and complex dosing formulations, regimens, and routes, to treat a disease with variable anatomic extent, there is considerable practice variability in the management of patients with mild-moderate UC. Hence, the American Gastroenterological Association prioritized clinical guidelines on this topic. To inform clinical guidelines, this technical review was developed in accordance with the Grading of Recommendations Assessment, Development and Evaluation framework for interventional studies. Focused questions included the following: (1) comparative effectiveness and tolerability of different oral 5-ASA therapies (sulfalsalazine vs diazo-bonded 5-ASAs vs mesalamine; low- (<2 g) vs standard (2-3 g/d) vs high-dose (>3 g/d) mesalamine); (2) comparison of different dosing regimens (once-daily vs multiple times per day dosing) and routes (oral vs rectal vs both oral and rectal); (3) role of oral budesonide in patients mild-moderate UC; (4) comparative effectiveness and tolerability of rectal 5-ASA and corticosteroid formulations in patients with distal colitis; and (5) role of alternative therapies like probiotics, curcumin, and fecal microbiota transplantation in the management of mild-moderate UC.
大多数溃疡性结肠炎 (UC) 患者的疾病活动度为轻至中度，结直肠切除风险低，由初级保健医生或胃肠病学家进行管理。优化这些患者的管理可降低疾病复发和近端疾病扩展的风险，并可能预防疾病进展、并发症和免疫抑制治疗的需要。对于这种具有可变解剖范围的疾病，有多种药物（例如柳氮磺胺吡啶、偶氮结合的 5-氨基水杨酸 [ASA]、美沙拉嗪和皮质类固醇，包括布地奈德）和复杂的剂量方案、方案和途径，因此在轻中度 UC 患者的管理中存在相当大的实践变异性。因此，美国胃肠病学会将该主题的临床指南列为优先事项。为了为临床指南提供信息，根据干预性研究的推荐评估、制定和评估框架制定了本技术审查。重点问题包括以下内容：(1) 不同口服 5-ASA 治疗药物（柳氮磺胺吡啶与偶氮结合的 5-ASAs 与美沙拉嗪；低剂量 (<2 g) 与标准剂量 (2-3 g/d) 与高剂量 (>3 g/d) 美沙拉嗪）的比较有效性和耐受性；(2) 不同剂量方案（每日一次与每日多次给药）和途径（口服与直肠与口服和直肠两者）的比较；(3) 口服布地奈德在轻度至中度 UC 患者中的作用；(4) 直肠 5-ASA 和皮质类固醇制剂在远端结肠炎患者中的比较有效性和耐受性；以及 (5) 益生菌、姜黄素和粪便微生物群移植等替代疗法在轻度至中度 UC 管理中的作用。
