Natasha Meunier-McVey | Editorial Assistant
KEY UPDATES to the European Crohn’s and Colitis Organisation (ECCO) Guidelines on the Medical and Surgical Treatment of Ulcerative Colitis (UC) were presented in an engaging session at the 17th Congress of ECCO, which took place from 16th–19th February 2022. Chaired by Konstantinos Karmiris, ECCO Education Committee member and consultant gastroenterologist, Venizeleio General Hospital, Heraklion, Greece, and Henit Yanai, Head of the Inflammatory Bowel Disease Center, Rabin Medical Center, Petah Tikva, Israel, the session took place on the penultimate day of the congress and explored therapeutic and surgical options for the treatment of UC.
KEY OBJECTIVES OF THE ECCO GUIDELINE UPDATE
The session was opened by Timothy Raine, ECCO Guidelines Committee member and consultant gastroenterologist at Addenbrooke’s Hospital, Cambridge, UK. Raine began by highlighting the key objectives of the updates to the ECCO Guidelines on the Medical Treatment of UC.
The goal of the 2022 update was to establish transparent and reproducible guidelines that are clinically relevant, whilst also recognising the lack of available data that is inevitable in some scenarios. Raine gave a clear explanation of the methodology used by experts in this year’s update, a nod to the initiative for more transparency in guidelines for healthcare professionals. The guidelines were drafted using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process, prompting the formation of clinically relevant questions and meta-analyses of the quality of existing evidence, ensuring a high standard of consensus recommendation. In areas where data lacked, the panellists employed the Oxford Levels of Evidence; this pragmatic approach involved a discussion of relevant papers following systematic review. These discussions took place in a face-to-face meeting of consensus group members with a panel of six expert patient representatives.
Raine went on to stress the importance of the outcomes measured by panellists for the medical section of the ECCO Guidelines on UC, in terms of what matters to patients and clinicians. Evidence supporting these outcomes was established through meta-analyses of data to accurately confirm treatment effects and risks associated with certain medications. Key areas of importance established for the medical treatment of UC included clinical response and remission for maintenance and induction therapies, as well as steroid-free clinical remission.
CHANGES TO THE MEDICAL TREATMENT OF ULCERATIVE COLITIS
Raine highlighted the key changes, referred to as ‘surprises’, in the update of the 2022 ECCO Guidelines on the Medical Treatment of UC. A notable shift from the 2017 guidelines is the recommendation of considering treatment options based on patient disease severity. Previously, guidelines advised treatment according to the site of the disease and its activity, whereas revised guidelines recommend treatment under sections labelled ‘Medical Management of Mildly-to-Moderately Active UC’ and ‘Medical Management of Moderately-to-Severely Active UC’. The decision to change this particular section aims to ensure that patients with limited disease who are displaying active symptoms have access to appropriate treatment options. A statement from the expert ECCO Guidelines Committee explained: “We feel that addressing the treatment choice to the clinical activity of a patient is appropriate.”
A notable change to the ECCO Guidelines on the Medical Treatment of UC is in regard to new data and treatments. Following the recent MERIT-UC trial conducted by Herfarth et al.,1 which took place in 2018 and concluded that methotrexate was not superior to a placebo in maintaining steroid-free response or remission in UC, the drug has been removed from the guidelines.1 New data for vedolizumab, ustekinumab, and tofacitinib have been included in the updated ECCO Therapeutic Guidelines on UC, which have purposefully been written in a way that allows for new updates to therapeutics to be included.
The committee took the deliberate decision to include head-to-head studies in the evidence review process. The first head-to-head biologic trial, the VARSITY study, was included in the updated guidelines. This showcases the importance of head-to-head trials, whilst ensuring that the outcomes included reflect those established as valuable by the committee. Indirect comparisons, such as references to external network meta-analyses, have also been included in the ECCO guideline update to allow for nuanced discussion of treatment hierarchies to take place in the supporting text. Raine wrapped up the therapeutic section of the session by emphasising the importance of clinicians referring to this supporting information for the most practical advice.
ECCO GUIDELINES ON SURGICAL TREATMENT OF ULCERATIVE COLITIS
Opening up the second part of the update on the ECCO Guidelines on the Surgical Treatment of UC, Yves Panis, Professor of Digestive Surgery, Beaujon Hospital, Paris, France, provided key updates to surgery in cases of moderate-to-severe UC. The first statement update outlined that reconstructive ileal pouch-anal anastomosis surgery can be offered to refractory and corticosteroid-dependent patients following evidence that this improves patient quality of life. Panis also touched on the importance of pre-operative optimisation in patients with moderate-to-severe UC. The key update focuses on the use of steroids pre-operatively, which should be markedly avoided or weaned off before restorative surgery. The new guidelines advise that where weaning is not possible, surgery should be postponed. Prophylactic anticoagulation therapy is also advised in adult patients with active UC to reduce the risk of venous thromboembolism, and systemic nutrition is advised despite a lack of evidence.
Variations on total colectomy procedures were also discussed, which can be performed in modified two- (with temporary stoma) or three-stage methods. The updated guidelines state that the modified two-stage procedure may be associated with fewer complications, as patients are subjected to less surgery, but more evidence is needed to confirm this.
For patients with medically refractory UC, laparoscopic ileal pouch-anal anastomosis surgery is the advised choice. Panis explained that the guideline statements of lower intra- and post-operative morbidity and faster recovery come from a wider pool of reliable evidence. This technique is also an ideal option for young females, as it is associated with improved fecundity compared to open surgery. Ileo-rectal anastomosis (IRA) remains an option for patients with UC who have a minimally affected rectum. Panis went on to present data from the GETAID trial, the largest IRA follow-up study to date. This multivariate analysis study highlighted that patients with UC by severe acute colitis who have short-lived disease, are naïve to biologics, and do not present with chronic pruritis have the best chance of a good IRA outcome.
Panis closed the surgical update by drawing attention to the following statement from ECCO: “In addition to the clinical questions addressed in these guidelines, we recognise that many other topics would have been worthy of discussion.” The statement lists areas such as the early post-operative management of patients with UC and acknowledges that the committee drafting process identified gaps in current knowledge, paving the way for future research.
Bringing the session to a close, Raine explained that although uncertainty remains in some areas of the guidelines, the update has provided healthcare professionals with robust and pragmatic advice, once again emphasising the importance of referring to the supporting text for practical advice from more specific clinical presentations. Overall, Raine explained that the 2022 ECCO Guidelines on the Treatment of UC have been designed to guide and complement clinical judgement, whilst leaving room for the patient perspective. These guidelines will undoubtedly optimise patient care through advising clinical decision-making and allowing for further research and developments in the field of UC.