Ulcerative colitis: management

This guideline covers managing ulcerative colitis in children, young people and adults. It aims to help professionals to provide consistent high-quality care and it highlights the importance of advice and support for people with ulcerative colitis.

# Recommendations
People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

# Patient information and support
Discuss the disease and associated symptoms, treatment options and monitoring:
with the person with ulcerative colitis and their family members or carers (as appropriate) and
within the multidisciplinary team (the composition of which should be appropriate for the age of the person) at every opportunity.Apply the principles in the NICE guideline on patient experience in adult NHS services. 
Discuss the possible nature, frequency and severity of side effects of drug treatment for ulcerative colitis with the person, and their family members or carers (as appropriate). Refer to the NICE guideline on medicines adherence. 
Give the person, and their family members or carers (as appropriate) information about their risk of developing colorectal cancer and about colonoscopic surveillance, in line with the NICE guidelines on colorectal cancer prevention: colonoscopic surveillance in adults with ulcerative colitis, Crohn's disease or adenomas and suspected cancer: recognition and referral. 

# Inducing remission in people with ulcerative colitis

## Treating mild-to-moderate ulcerative colitis
To induce remission in people with a mild-to-moderate first presentation or inflammatory exacerbation of proctitis, offer a topical aminosalicylate as first-line treatment. In May 2019, this was an off-label use of some topical aminosalicylates for children and young people. See NICE's information on prescribing medicines.
If remission is not achieved within 4 weeks, consider adding an oral aminosalicylate. In May 2019, this was an off-label use of some oral aminosalicylates for children and young people. See NICE's information on prescribing medicines.
If further treatment is needed, consider adding a time-limited course of a topical or an oral corticosteroid. In May 2019, this was an off-label use of beclometasone dipropionate in most situations. See NICE's information on prescribing medicines.
For people who decline a topical aminosalicylate:
consider an oral aminosalicylate as first-line treatment, and explain that this is not as effective as a topical aminosalicylate
if remission is not achieved within 4 weeks, consider adding a time-limited course of a topical or an oral corticosteroid. In May 2019, this was an off-label use of beclometasone dipropionate in most situations. See NICE's information on prescribing medicines.
For people who cannot tolerate aminosalicylates, consider a time-limited course of a topical or an oral corticosteroid. 
To induce remission in people with a mild-to-moderate first presentation or inflammatory exacerbation of proctosigmoiditis or left-sided ulcerative colitis, offer a topical aminosalicylate as first-line treatment. 
If remission is not achieved within 4 weeks, consider:
adding a high-dose oral aminosalicylate to the topical aminosalicylate or
switching to a high-dose oral aminosalicylate and a time-limited course of a topical corticosteroid. 
If further treatment is needed, stop topical treatments and offer an oral aminosalicylate and a time-limited course of an oral corticosteroid. 
For people who decline any topical treatment:
consider a high-dose oral aminosalicylate alone, and explain that this is not as effective as a topical aminosalicylate
if remission is not achieved within 4 weeks, offer a time-limited course of an oral corticosteroid in addition to the high-dose aminosalicylate. 
For people who cannot tolerate aminosalicylates, consider a time-limited course of a topical or an oral corticosteroid. 
To induce remission in people with a mild-to-moderate first presentation or inflammatory exacerbation of extensive ulcerative colitis, offer a topical aminosalicylate and a high-dose oral aminosalicylate as first-line treatment. 
If remission is not achieved within 4 weeks, stop the topical aminosalicylate and offer a high-dose oral aminosalicylate with a time-limited course of an oral corticosteroid. 
For people who cannot tolerate aminosalicylates, consider a time-limited course of an oral corticosteroid. 

## Biologics and Janus kinase inhibitors for moderately to severely active ulcerative colitis: all extents of disease
For guidance on biologics and Janus kinase inhibitors for treating moderately to severely active ulcerative colitis, see the:
NICE technology appraisal guidance on infliximab, adalimumab and golimumab for moderately to severely active ulcerative colitis
NICE technology appraisal guidance on vedolizumab for treating moderately to severely active ulcerative colitis
NICE technology appraisal guidance on tofacitinib for moderately to severely active ulcerative colitis. 
For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on inducing remission in people with mild-to-moderate ulcerative colitis .
Full details of the evidence and the committee's discussion are in evidence review: induction of remission in mild-to-moderate ulcerative colitis.
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## Treating acute severe ulcerative colitis: all extents of disease
For people admitted to hospital with acute severe ulcerative colitis:
ensure that a gastroenterologist and a colorectal surgeon collaborate to provide treatment and management
ensure that the composition of the multidisciplinary team is appropriate for the age of the person
seek advice from a paediatrician with expertise in gastroenterology when treating a child or young person
ensure that the obstetric and gynaecology team is included when treating a pregnant woman. 
For people admitted to hospital with acute severe ulcerative colitis (either a first presentation or an inflammatory exacerbation):
-ffer intravenous corticosteroids to induce remission and
assess the likelihood that the person will need surgery (see the recommendation on assess and document in the section on assessing likelihood of needing surgery). 
Consider intravenous ciclosporin or surgery for people:
who cannot tolerate or who decline intravenous corticosteroids or
for whom treatment with intravenous corticosteroids is contraindicated.Take into account the person's preferences when choosing treatment. In May 2019, this was an off-label use of ciclosporin. See NICE's information on prescribing medicines.
Consider adding intravenous ciclosporin to intravenous corticosteroids or consider surgery for people:
who have little or no improvement within 72 hours of starting intravenous corticosteroids or
whose symptoms worsen at any time despite corticosteroid treatment.Take into account the person's preferences when choosing treatment. In May 2019, this was an off-label use of ciclosporin. See NICE's information on prescribing medicines
Infliximab is recommended as an option for the treatment of acute exacerbations of severely active ulcerative colitis only in patients in whom ciclosporin is contraindicated or clinically inappropriate, based on a careful assessment of the risks and benefits of treatment in the individual patient. 
In people who do not meet the criterion in the recommendation above on the use of infliximab in patients in whom ciclosporin is contraindicated or clinically inappropriate, infliximab should only be used for the treatment of acute exacerbations of severely active ulcerative colitis in clinical trials.  

## Monitoring treatment
Ensure that there are documented local safety monitoring policies and procedures (including audit) for adults, children and young people receiving treatment that needs monitoring (aminosalicylates, tacrolimus, ciclosporin, infliximab, azathioprine and mercaptopurine). Nominate a member of staff to act on abnormal results and communicate with GPs and people with ulcerative colitis and their family members or carers (as appropriate). 

## Assessing likelihood of needing surgery
Assess and document on admission, and then daily, the likelihood of needing surgery for people admitted to hospital with acute severe ulcerative colitis. 
Be aware that there may be an increased likelihood of needing surgery for people with any of the following:
stool frequency more than 8 per day
pyrexia
tachycardia
an abdominal Xray showing colonic dilatation
low albumin, low haemoglobin, high platelet count or Creactive protein above 45 mg/litre (bear in mind that normal values may be different in pregnant women). 

# Information about treatment options for people who are considering surgery
These recommendations apply to anyone with ulcerative colitis considering elective surgery. The principles can also be applied to people requiring emergency surgery.

## Information when considering surgery
For people with ulcerative colitis who are considering surgery, ensure that a specialist (such as a gastroenterologist or a nurse specialist) gives the person and their family members or carers (as appropriate) information about all available treatment options, and discusses this with them. Information should include the benefits and risks of the different treatments and the potential consequences of no treatment. 
Ensure that the person and their family members or carers (as appropriate) have sufficient time and opportunities to think about the options and the implications of the different treatments. 
Ensure that a colorectal surgeon gives any person who is considering surgery and their family members or carers (as appropriate) specific information about what they can expect in the short and long term after surgery, and discusses this with them. 
Ensure that a specialist (such as a colorectal surgeon, a gastroenterologist, an inflammatory bowel disease nurse specialist or a stoma nurse) gives any person who is considering surgery and their family members or carers (as appropriate) information about:
diet
sensitive topics such as sexual function
effects on lifestyle
psychological wellbeing
the type of surgery, the possibility of needing a stoma and stoma care. 
Ensure that a specialist who is knowledgeable about stomas (such as a stoma nurse or a colorectal surgeon) gives any person who is having surgery and their family members or carers (as appropriate) specific information about the siting, care and management of stomas. 

## Information after surgery
After surgery, ensure that a specialist who is knowledgeable about stomas (such as a stoma nurse or a colorectal surgeon) gives the person and their family members or carers (as appropriate) information about managing the effects on bowel function. This should be specific to the type of surgery performed (ileostomy or ileoanal pouch) and could include the following:
strategies to deal with the impact on their physical, psychological and social wellbeing
where to go for help if symptoms occur
sources of support and advice. 

# Maintaining remission in people with ulcerative colitis

## 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 aminosalicylate alone (daily or intermittent) or
an oral aminosalicylate plus a topical aminosalicylate (daily or intermittent) or
an oral aminosalicylate alone, explaining that this may not be as effective as combined treatment or an intermittent topical aminosalicylate alone. In May 2019, note that this was an off-label use of some aminosalicylates for children and young people. See NICE's information on prescribing medicines

## Left-sided and extensive ulcerative colitis
To maintain remission in adults after a mild-to-moderate inflammatory exacerbation of left-sided or extensive ulcerative colitis:
-ffer a low maintenance dose of an oral aminosalicylate
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 ulcerative colitis:
-ffer an oral aminosalicylate (dosing requirements for children should be calculated by body weight, as described in the BNF)
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. In May 2019, this was an off-label use of some oral aminosalicylates for children and young people. See NICE's information on prescribing medicines.

## All extents of disease
Consider oral azathioprine or oral mercaptopurine to maintain remission:
after 2 or more inflammatory exacerbations in 12 months that require treatment with systemic corticosteroids or
if remission is not maintained by aminosalicylates. In May 2019, this was an off-label use of some brands of azathioprine and mercaptopurine. See NICE's information on prescribing medicines.
To maintain remission after a single episode of acute severe ulcerative colitis:
consider oral azathioprine or oral mercaptopurine
consider oral aminosalicylates if azathioprine and/or mercaptopurine are contraindicated or the person cannot tolerate them. In May 2019, this was an off-label use of some brands of azathioprine and mercaptopurine. See NICE's information on prescribing medicines.

## Dosing regimen for oral aminosalicylates
Consider a once-daily dosing regimen for oral aminosalicylates when used for maintaining remission. Take into account the person's preferences, and explain that once-daily dosing can be more effective, but may result in more side effects. In May 2019, this was an off-label use of some oral aminosalicylates. See NICE's information on prescribing medicines.

# Pregnant women
When caring for a pregnant woman with ulcerative colitis:
Ensure effective communication and information-sharing across specialties (for example, primary care, obstetrics and gynaecology, and gastroenterology).
Give her information about the potential risks and benefits of medical treatment to induce or maintain remission and of not having treatment, and discuss this with her. Include information relevant to a potential admission for an acute severe inflammatory exacerbation. 

# Monitoring

## Monitoring bone health
For recommendations on assessing the risk of fragility fracture in adults, refer to the NICE guideline on osteoporosis: assessing the risk of fragility fracture. 
Consider monitoring bone health in children and young people with ulcerative colitis in the following circumstances:
during chronic active disease
after treatment with systemic corticosteroids
after recurrent active disease. 

## Monitoring growth and pubertal development in children and young people
Monitor the height and body weight of children and young people with ulcerative colitis against expected values on centile charts (and/or z scores) at the following intervals according to disease activity:
every 3 to 6 months:
if they have an inflammatory exacerbation and are approaching or undergoing puberty or
if there is chronic active disease or
if they are being treated with systemic corticosteroids
every 6 months during pubertal growth if the disease is inactive
every 12 months if none of the criteria above are met. 
Monitor pubertal development in young people with ulcerative colitis using the principles of Tanner staging, by asking screening questions and/or carrying out a formal examination. 
Consider referral to a secondary care paediatrician for pubertal assessment and investigation of the underlying cause if a young person with ulcerative colitis:
has slow pubertal progress or
has not developed pubertal features appropriate for their age. 
Monitoring of growth and pubertal development:
can be done in a range of locations (for example, at routine appointments, acute admissions or urgent appointments in primary care, community services or secondary care)
should be carried out by appropriately trained healthcare professionals as part of the overall clinical assessment (including disease activity) to help inform the need for timely investigation, referral and/or interventions, particularly during pubertal growth.If the young person prefers self-assessment for monitoring pubertal development, this should be allowed if possible and they should be instructed on how to do this. 
Ensure that relevant information about monitoring of growth and pubertal development and about disease activity is shared across services (for example, community, primary, secondary and specialist services). Apply the principles in the NICE guideline on patient experience in adult NHS services in relation to continuity of care. 

# Terms used in this guideline

## Mild, moderate and severe ulcerative colitis
In this guideline, the categories of mild, moderate and severe are used to describe ulcerative colitis:
In adults these categories are based on the Truelove and Witts' severity index (see table 1). This table is adapted from the Truelove and Witts' criteria.
In children and young people these categories are based on the Paediatric Ulcerative Colitis Activity Index (PUCAI; see table 2).
Mild
Moderate
Severe
Bowel movements (number per day)
Fewer than 4
-r more plus at least 1 of the features of systemic upset (marked with - below)
Blood in stools
No more than small amounts of blood
Between mild and severe
Visible blood
Pyrexia (temperature greater than 37.8C) *
No
No
Yes
Pulse rate greater than 90 bpm *
No
No
Yes
Anaemia *
No
No
Yes
Erythrocyte sedimentation rate (mm/hour) *
-r below
-r below
Above 30
 Copyright British Medical Journal, 29 October 1955. Reproduced with permission.
Disease severity in table 2 is defined by the following scores:
severe: 65 or above
moderate: 3564
mild: 1034
remission (disease not active): below 10.
Item
Points
Abdominal pain
No pain
Pain can be ignored
Pain cannot be ignored
Rectal bleeding
None
Small amount only, in less than 50% of stools
Small amount with most stools
Large amount (50% of the stool content)
Stool consistency of most stools
Formed
Partially formed
Completely unformed
Number of stools per 24 hours
Nocturnal stools (any episode causing wakening)
No
Yes
Activity level
No limitation of activity
Occasional limitation of activity
Severe restricted activity
Sum of PUCAI (085)
 Copyright The Hospital for Sick Children, Toronto, Canada, 2006. Reproduced with permission.

## Time-limited course of oral corticosteroids
A course of corticosteroids used to treat active disease, normally given for 4 to 8 weeks (depending on the steroid).# Recommendations for research
The guideline committee has made the following recommendations for research. As part of the 2019 update, the guideline committee made an additional 3 research recommendations on inducing remission in mild-to-moderate ulcerative colitis.

# Key recommendations for research

## The effectiveness of immunomodulators in inducing remission in proctitis
In a mild-to-moderate first presentation or inflammatory exacerbation of proctitis that is resistant to standard treatment, what is the effectiveness of topical immunomodulators, such as tacrolimus, in achieving clinical remission and what is the most effective formulation (suppository/ointment)?
For a short explanation of why the committee made the recommendation for research, see the rationale on proctitis .
Full details of the evidence and the committee's discussion are in evidence review: induction of remission in mild-to-moderate ulcerative colitis.
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## The effectiveness of immunomodulators in unresponsive ulcerative colitis
What is the effectiveness of oral tacrolimus and systemic (intramuscular/subcutaneous/oral) methotrexate in the induction of remission in mild-to-moderate ulcerative colitis unresponsive to aminosalicylates?
For a short explanation of why the committee made the recommendation for research, see the rationale on extensive ulcerative colitis .
Full details of the evidence and the committee's discussion are in evidence review: induction of remission in mild-to-moderate ulcerative colitis.
Loading. Please wait.

## The relative effectiveness of corticosteroids for inducing remission in ulcerative colitis
What is the clinical and cost effectiveness of prednisolone, budesonide, and beclometasone in addition to aminosalicylates compared with each other and with aminosalicylate monotherapy for the induction of remission for people with mild-to-moderate ulcerative colitis?
For a short explanation of why the committee made the recommendation for research, see the rationale on all extents of disease .
Full details of the evidence and the committee's discussion are in evidence review: induction of remission in mild-to-moderate ulcerative colitis.
Loading. Please wait.

# Other recommendations for research

## From the 2019 update
What is the clinical and cost effectiveness of prednisolone compared with aminosalicylates for the induction of remission for people with moderate ulcerative colitis?
What is the clinical and cost effectiveness of prednisolone plus an aminosalicylate compared with beclometasone plus an aminosalicylate for induction of remission for people with moderate ulcerative colitis?
What are the benefits, risks and cost effectiveness of methotrexate, ciclosporin, tacrolimus, adalimumab and infliximab compared with each other and with placebo for induction of remission for people with subacute ulcerative colitis that is refractory to systemic corticosteroids?

## From the 2013 guideline
What are the benefits, risks and cost effectiveness of methotrexate, ciclosporin, tacrolimus, adalimumab and infliximab compared with each other and with placebo for induction of remission for people with subacute ulcerative colitis that is refractory to systemic corticosteroids?
What is the clinical and cost effectiveness of regular maintenance treatment compared with no regular treatment (but rapid standard treatment if a relapse occurs) in specific populations with mild to moderate ulcerative colitis?
To develop and validate a risk tool that predicts the likelihood of needing surgery for adults admitted to hospital with acute severe ulcerative colitis.
In children and young people with ulcerative colitis receiving steroid treatment, what are the clinical benefits of routine monitoring of bone density, what tests should be done and how frequently?
A registry to collect data to answer 'What are the potential harms or benefits of drug treatments in pregnant women with ulcerative colitis?'
What are the information needs of people with ulcerative colitis when they are considering surgery?
What is the clinical and cost effectiveness of sulphasalazine compared to high-dose branded mesalazine for induction of remission for people with mild moderate ulcerative colitis?
What is the validity, reliability and accuracy of available adult risk tools as a predictor for the need for surgery in people admitted into hospital with acute severe ulcerative colitis?
What is the validity, reliability and accuracy of the paediatric ulcerative colitis activity index (PUCAI) as a predictor for surgery for children and young people admitted to hospital with acute severe colitis?
In people with mild to moderate ulcerative colitis, what are the best second-line treatment strategies for induction of remission after people have failed to respond to ASA mono or combination therapies?
In people with subacute ulcerative colitis, what are the best second-line treatment strategies for induction of remission after people have failed to respond to oral prednisolone?
In people with mild to moderate ulcerative colitis, what are the best strategies for the induction of remission after people have failed to respond to tacrolimus?
Establish a national registry to identify the incidence of growth failure and/or pubertal delay in ulcerative colitis and the relationship with treatment (to record treatment  and growth ).# Rationale and impact
This section briefly explains why the committee made the recommendations and how they might affect practice. It links to details of the evidence and a full description of the committee's discussion.

# Inducing remission in people with mild-to-moderate ulcerative colitis
Recommendations 1.2.1 to 1.2.14

## Why the committee made the recommendations
The evidence showed that topical aminosalicylates (suppositories or enema) are the most effective treatments for achieving remission in people with mild-to-moderate proctitis, so these were recommended as first-line treatments. The evidence did not show any difference in effectiveness between enema and suppository.
Topical aminosalicylates alone are recommended for up to 4 weeks because the evidence showed that they were the most effective treatment within this timeframe. There was no direct evidence for combining topical and oral aminosalicylates for people with proctitis. However, evidence showed that this combination was effective for people with proctosigmoiditis, and the committee agreed that this evidence was also applicable to people with proctitis alone. The committee chose not to specify a dose for the oral aminosalicylate. It preferred to leave it open to clinical judgment depending on the specific situation (for example, the clinician could give a low dose if the person had not taken an aminosalicylate before, or a high dose if the person was already taking a low dose).
Some people will not achieve remission with topical and oral aminosalicylates. In clinical practice, oral or topical corticosteroids are commonly added at this stage, but there was no evidence on this combination. The committee agreed that, based on their experience, adding a topical or oral corticosteroid should be an option at this stage.
Despite the lack of direct evidence for the effectiveness of topical or oral corticosteroids, the committee agreed that, based on their experience, these should also be an option for people who cannot tolerate aminosalicylates.
Some people decline topical treatment, preferring oral to topical aminosalicylates. This is more common in children and young people, although proctitis is not common in this group. As the evidence showed that oral aminosalicylates are not as effective at inducing remission, the committee thought it was important to explain this to people who decline topical aminosalicylates.
There was cost-effectiveness evidence showing that using an immunomodulator as the next line of treatment after oral or topical corticosteroids and oral aminosalicylate produced greater health benefits at lower total costs than other strategies. However, the clinical evidence on topical immunomodulators was limited and it was unclear how applicable it was to UK clinical practice. Because of this, the committee recommended the sequence without this final treatment, and made a research recommendation on topical immunomodulators.
There is evidence that topical aminosalicylates are effective for achieving remission in people with mild-to-moderate proctosigmoiditis or left-sided ulcerative colitis. In the committee's experience topical aminosalicylates also work faster and more effectively than topical corticosteroids. Topical aminosalicylates alone are recommended for up to 4 weeks because the evidence showed that they were effective within this timeframe. Cost-effectiveness evidence also showed that treatment sequences starting with topical aminosalicylates produced greater health benefits and incurred lower total costs than other strategies.
There is no direct evidence for the effectiveness of high-dose oral aminosalicylates combined with either topical aminosalicylates or topical corticosteroids. However, there is evidence that topical treatments or high-dose oral aminosalicylates individually provide some benefit. Therefore, the committee agreed it was reasonable to recommend combinations of these if remission is not achieved. While there was limited evidence for oral corticosteroids, in the committee's experience an oral corticosteroid may benefit people with proctosigmoiditis or left-sided disease if further treatment is needed. As a result, they recommended oral corticosteroids with oral aminosalicylates instead of topical treatment for these people. This reflects current practice for people who do not achieve remission with topical treatments and high-dose oral aminosalicylates.
The evidence showed that people with mild-to-moderate extensive ulcerative colitis would benefit most from a combination of high-dose oral aminosalicylates with topical aminosalicylates as first-line treatment. High-dose oral aminosalicylates combined with topical aminosalicylates are recommended for up to 4 weeks, because in the committee's experience they are the most effective treatment within this timeframe. There is evidence that an oral corticosteroid combined with a high-dose oral aminosalicylate is also effective, so the committee recommended this combination if remission is not achieved with aminosalicylates alone. In people who cannot tolerate aminosalicylates, oral corticosteroids are recommended as they are also an effective treatment option.
The sequence of drugs recommended was more effective than starting with a high-dose oral aminosalicylate alone. There was some uncertainty around the cost effectiveness of this sequence. The data on the effectiveness of high-dose oral aminosalicylates combined with topical aminosalicylates was from an 8week clinical trial. The committee believed that in practice, people whose disease did not respond to treatment within 4 weeks would switch to another treatment. When the cost-effectiveness analysis allowed for early switching, the combination of a high-dose oral aminosalicylate and topical aminosalicylate was not cost effective. However, if it was assumed that everyone continued treatment as described in the trial, the combination of a high-dose oral aminosalicylate and topical aminosalicylate was more likely to be cost effective. The committee took the uncertainty about the cost-effectiveness results in the different scenarios into account in recommending the combination as first-line treatment.
There was some evidence on methotrexate for inducing remission, but it did not show a clear benefit, and there was no evidence on oral tacrolimus. To address these gaps in the evidence, the committee made a research recommendation on the effectiveness of immunomodulators in unresponsive ulcerative colitis.
Most of the evidence was for adults. However, the committee agreed to generalise the recommendations to all people with a mild-to-moderate exacerbation or first presentation of ulcerative colitis.
There is limited evidence on oral corticosteroids. In addition, the committee agreed that the use of oral corticosteroids is generally reserved for later lines of treatment because of concerns about side effects. It is not clear which corticosteroid is most effective for each extent of disease. There is also limited evidence on immunomodulators, specifically oral tacrolimus and systemic methotrexate for each extent of disease. The committee made a research recommendation on corticosteroids for the induction of remission in mild-to-moderate ulcerative colitis to address these uncertainties.

## How the recommendations might affect practice
The new recommendations classify the extents of ulcerative colitis differently. This more closely reflects current practice, so will be clearer and more informative for people with mild-to-moderate ulcerative colitis and healthcare professionals.
The recommendations in the 2013 guideline referred to specific corticosteroids. To better reflect the available evidence, the updated recommendations refer to aminosalicylates and corticosteroids as a class rather than recommending individual treatments. This allows healthcare professionals and people with mild-to-moderate ulcerative colitis to choose the most appropriate corticosteroid or aminosalicylate, depending on patient preference, availability and acquisition cost.
The new recommendations specify that courses of oral corticosteroids should be time-limited. This should address varying practice in prescribing for some corticosteroids.
Return to recommendations# Context
Ulcerative colitis is the most common type of inflammatory bowel disease. There are around 146,000 people in the UK with a diagnosis of ulcerative colitis (Crohn's & Colitis UK). The cause of ulcerative colitis is unknown. It can develop at any age, but peak incidence is between the ages of 15 and 25 years, with a second, smaller peak between 55 and 65 years (although this second peak has not been universally demonstrated).
Ulcerative colitis usually affects the rectum, and a variable extent of the colon proximal to the rectum. The inflammation is continuous in extent. Inflammation of the rectum is referred to as proctitis, and inflammation of the rectum and sigmoid as proctosigmoiditis. Left-sided colitis refers to disease involving the colon distal to the splenic flexure. Extensive colitis affects the colon proximal to the splenic flexure, and includes pan-colitis, where the whole colon is involved.
Symptoms of active disease or relapse include bloody diarrhoea, an urgent need to defecate and abdominal pain.
Ulcerative colitis is a lifelong disease that is associated with significant morbidity. It can also affect a person's social and psychological wellbeing, particularly if poorly controlled. Typically, it has a relapsing-remitting pattern.
Current medical approaches focus on treating active disease to address symptoms, to improve quality of life, and thereafter to maintain remission. The long-term benefits of achieving mucosal healing remain unclear. The treatment chosen for active disease is likely to depend on clinical severity, extent of disease and the person's preference, and may include the use of aminosalicylates, corticosteroids or biological drugs. These drugs can be oral or topical (into the rectum), and corticosteroids may be administered intravenously in people with acute severe disease. Surgery may be considered as emergency treatment for severe ulcerative colitis that does not respond to drug treatment. People may also choose to have elective surgery for unresponsive or frequently relapsing disease that is affecting their quality of life.
Advice and support for people with ulcerative colitis is important, in terms of discussing the effects of the condition and its course, medical treatment options, the effects of medication and the monitoring required. Around 10% of inpatients with inflammatory bowel disease reported a lack of information about drug side effects on discharge from hospital. Information to support decisions about surgery is also essential, both for clinicians and for people facing the possibility of surgery. This includes recognising adverse prognostic factors for people admitted with acute severe colitis to enable timely decisions about escalating medical therapy or predicting the need for surgery. It is also very important to provide relevant information to support people considering elective surgery.
The wide choice of drug preparations and dosing regimens, the judgement required in determining the optimum timing for surgery (both electively and as an emergency) and the importance of support and information may lead to variation in practice across the UK. This guideline aims to address this variation, and to help healthcare professionals to provide consistent high-quality care. Managing ulcerative colitis in adults and children overlaps in many regards, so the guideline incorporates advice that is applicable to children and young people, which again should help to address potential inconsistencies in practice.