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NICE's original guidance on Ulcerative colitis: management in adults, children and young people was published in June 2013 and has undergone an update, published in May 2019. This document preserves evidence reviews and committee discussions for areas of the guideline that have not been updated in 2019. Black shading in the PDF indicates text from 2013 replaced by the 2019 update.
Excerpt
NICE's original guidance on Ulcerative colitis: management in adults, children and young people was published in June 2013 and has undergone an update, published in May 2019
Ulcerative colitis is the most common type of inflammatory disease of the bowel. It has an incidence in the UK of approximately 10 per 100,000 people annually,and a prevalence of approximately 240 per 100,000. This amounts to around 146,000 people in the UK with a diagnosis of ulcerative colitis. 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). The British Paediatric Surveillance Unit reported an incidence of ulcerative colitis in children aged younger than 16 years in the United Kingdom, of 1.4 per 100,000 with a greater proportion of Asian children having ulcerative colitis than other children. The median age for diagnosis of ulcerative colitis overall in this childhood cohort was 11.7 years (range 9.3 to 13.7 years).
Care of people with ulcerative colitis is usually shared between primary care and specialist gastroenterology units working in collaboration with specialist colorectal surgical units. Close links are required to allow specialist input, rapid access to advice (especially when symptoms worsen) and coordinated monitoring of drug-side effects, and to ensure that associated issues (such as monitoring of bone density) are addressed. However, the number of adults with ulcerative colitis definitely under specialist care may not be as high as thought, and may be as low as 30%. The most appropriate setting for a person’s care is likely to come under increasing scrutiny as commissioning groups seek to provide more care in the community.
This guideline therefore covers areas defined within the scope (Appendix A). Detailed delineation of areas excluded is given in the scope, but it should be noted that this guideline does not address areas of diagnosis, diagnostic investigation and surgical technique. Chapter 5 deals with induction of remission - the treatment of patients with active disease in relapse. This includes disease of limited extent (proctitis and proctosigmoiditis) and more extensive ulcerative colitis and includes treatment of acute severe colitis. In association with this, assessment of patients with acute severe colitis and their risk of requiring surgery or escalation of therapy are considered. Following this, drug treatment to maintain remission is examined and then considerations of information for people considering elective surgery, considerations of pregnancy in women with ulcerative colitis and bone health and growth and development in children.
Contents
- Guideline development group members
- Acknowledgments
- 1. Introduction
- 2. Development of the guideline
- 3. Methods
- 4. Guideline summary
- 5. Inducing remission in people with ulcerative colitis
- 5.1. Clinical introduction: Pharmacological treatment
- 5.2. Review question: In adults, children and young people with mild to moderate ulcerative colitis, what is the clinical and cost-effectiveness of corticosteroids, aminosalicylates and immunomodulators (mercaptopurine, azathioprine, methotrexate and tacrolimus) for the induction of remission compared to themselves (different preparations and doses), each other, combinations of preparations (oral and topical) and placebo?
- 5.3. Clinical evidence: Topical aminosalicylates
- 5.4. Evidence profile
- 5.5. Economic evidence
- 5.6. Evidence statements
- 5.7. Clinical evidence: Topical corticosteroids
- 5.8. Evidence profile
- 5.9. Economic evidence
- 5.10. Evidence statements
- 5.11. Clinical evidence: Topical aminosalicylates versus topical corticosteroids
- 5.12. Evidence profile
- 5.13. Economic evidence
- 5.14. Evidence statements
- 5.15. Clinical evidence: Oral aminosalicylates
- 5.16. Evidence profile
- 5.17. Economic evidence
- 5.18. Evidence statements
- 5.19. Clinical evidence: Oral corticosteroids
- 5.20. Evidence profile
- 5.21. Economic evidence
- 5.22. Evidence statements
- 5.23. Clinical evidence: Oral aminosalicylates versus oral corticosteroids
- 5.24. Evidence profile
- 5.25. Economic evidence
- 5.26. Evidence statements
- 5.27. Clinical evidence: Topical aminosalicylates versus oral aminosalicylates
- 5.28. Evidence profile
- 5.29. Economic evidence
- 5.30. Evidence statements
- 5.31. Clinical evidence: Topical corticosteroids versus oral corticosteroids
- 5.32. Economic evidence
- 5.33. Evidence statements
- 5.34. Network meta-analysis
- 5.35. Health economic induction model summary
- 5.36. Clinical evidence: Immunomodulators
- 5.37. Evidence profile
- 5.38. Economic evidence
- 5.39. Evidence statements
- 5.40. Recommendations and link to evidence
- 5.41. Review question: In adults, children and young people with acute severe ulcerative colitis, what is the clinical and cost-effectiveness of corticosteroids and ciclosporin compared to each other and their combination (corticosteroids and ciclosporin) for the induction of remission?
- 5.42. Clinical evidence: Acute severe ulcerative colitis
- 5.43. Evidence profile
- 5.44. Economic evidence
- 5.45. Evidence statements
- 5.46. Recommendations and link to evidence
- 5.47. Clinical introduction: Assessing likelihood of needing surgery
- 5.48. Review question: Which validated tools are the most predictive of the likelihood of surgery in people with acute severe ulcerative colitis?
- 5.49. Clinical evidence: Timing of surgery
- 5.50. Evidence profile
- 5.51. Economic evidence
- 5.52. Evidence summary
- 5.53. Recommendations and link to evidence
- 6. Information on surgery
- 6.1. Clinical introduction
- 6.2. Review question: For adults, children and young people with ulcerative colitis considering surgery, what information on short and long term outcomes should be offered to patients and their carers by healthcare professionals?
- 6.3. Clinical evidence
- 6.4. Summary of the evidence
- 6.5. Economic evidence
- 6.6. Recommendations and link to evidence
- 7. Maintaining remission in people with ulcerative colitis
- 7.1. Clinical introduction
- 7.2. Review question: In adults, children and young people with ulcerative colitis in remission, what is the clinical and cost-effectiveness of corticosteroids, aminosalicylates, immunomodulators (mercaptopurine, azathioprine, methotrexate and tacrolimus) for the maintenance of remission compared to themselves (different preparations and doses), each other, combinations of preparations (oral and topical) and placebo?
- 7.3. Clinical evidence: Topical aminosalicylates
- 7.4. Evidence profile
- 7.5. Economic evidence
- 7.6. Evidence statements
- 7.7. Clinical evidence: Topical corticosteroids
- 7.8. Evidence profile
- 7.9. Economic evidence
- 7.10. Evidence statements
- 7.11. Clinical evidence: Oral aminosalicylates
- 7.12. Evidence profile
- 7.13. Economic evidence
- 7.14. Evidence statements
- 7.15. Clinical evidence: Combinations of treatments
- 7.16. Evidence profile
- 7.17. Economic evidence
- 7.18. Evidence statements
- 7.19. Network meta-analysis
- 7.20. Health economic maintenance model summary
- 7.21. Clinical evidence: Immunomodulators
- 7.22. Evidence profile
- 7.23. Economic evidence
- 7.24. Evidence statements
- 7.25. Recommendations and link to evidence
- 8. Pregnant women
- 9. Monitoring
- 9.1. Clinical introduction: monitoring bone health
- 9.2. Review question: In children and young people with ulcerative colitis, are disease activity, systemic corticosteroid use, total vitamin D and malnutrition, risk factors for poor bone health?
- 9.3. Clinical evidence: monitoring bone health in children and young people
- 9.4. Evidence profile
- 9.5. Economic evidence
- 9.6. Evidence statements
- 9.7. Recommendations and link to evidence
- 9.8. Clinical introduction: monitoring growth and pubertal development in children and young people
- 9.9. Review question: In children and young people with ulcerative colitis, what are the optimal strategies (timing, location) for monitoring growth?
- 9.10. Clinical evidence: monitoring growth and pubertal development
- 9.11. Economic evidence
- 9.12. Evidence statements
- 9.13. Recommendations and link to evidence
- 10. Reference list
- 11. Acronyms and abbreviations
- 12. Glossary
- Appendix A. Scope
- Appendix B. Declarations of interest
- Appendix C. Review protocols
- Appendix D. Literature search strategies
- Appendix E. Study selection flowcharts
- Appendix F. Excluded studies
- Appendix A-F References
- Appendix G. Evidence tables
- Appendix H. Forest plots and ROC curves
- Appendix I. Induction NMA
- Appendix J. Maintenance NMA
- Appendix K. Costs of drugs used in the treatment of ulcerative colitis
- Appendix L. Cost-effectiveness analyses
- Appendix M. Research recommendations
- Appendix N. Author definitions
- Appendix H-N References
Disclaimer: Healthcare professionals are expected to take NICE clinical guidelines fully into account when exercising their clinical judgement. However, the guidance does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of each patient, in consultation with the patient and/or their guardian or carer.
- Generalized Pyoderma Gangrenosum Associated with Ulcerative Colitis: Successful Treatment with Infliximab and Azathioprine.[Acta Dermatovenerol Croat. 2016]Generalized Pyoderma Gangrenosum Associated with Ulcerative Colitis: Successful Treatment with Infliximab and Azathioprine.Chatzinasiou F, Polymeros D, Panagiotou M, Theodoropoulos K, Rigopoulos D. Acta Dermatovenerol Croat. 2016 Apr; 24(1):83-5.
- Birth outcome in women with ulcerative colitis and Crohn's disease, and pharmacoepidemiological aspects of anti-inflammatory drug therapy.[Dan Med Bull. 2011]Birth outcome in women with ulcerative colitis and Crohn's disease, and pharmacoepidemiological aspects of anti-inflammatory drug therapy.Nørgård BM. Dan Med Bull. 2011 Dec; 58(12):B4360.
- Surgery for Ulcerative Colitis in the White British and South Asian Populations in Selected Trusts in England 2001-2020: An Absence of Disparate Care and a Need for Specialist Centres.[J Clin Med. 2022]Surgery for Ulcerative Colitis in the White British and South Asian Populations in Selected Trusts in England 2001-2020: An Absence of Disparate Care and a Need for Specialist Centres.Farrukh A, Mayberry JF. J Clin Med. 2022 Aug 24; 11(17). Epub 2022 Aug 24.
- Review Cyclosporine A for induction of remission in severe ulcerative colitis.[Cochrane Database Syst Rev. 2005]Review Cyclosporine A for induction of remission in severe ulcerative colitis.Shibolet O, Regushevskaya E, Brezis M, Soares-Weiser K. Cochrane Database Syst Rev. 2005 Jan 25; (1):CD004277. Epub 2005 Jan 25.
- Review Oral 5-aminosalicylic acid for induction of remission in ulcerative colitis.[Cochrane Database Syst Rev. 2012]Review Oral 5-aminosalicylic acid for induction of remission in ulcerative colitis.Feagan BG, Macdonald JK. Cochrane Database Syst Rev. 2012 Oct 17; 10:CD000543. Epub 2012 Oct 17.
- Ulcerative ColitisUlcerative Colitis
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