Raymond Cross, MD, on Managing Mild to Moderate Ulcerative Colitis

Raymond Cross, MD, discusses his presentation from the September 12 virtual Advances in Inflammatory Bowel Disease regional meeting on management of mild to moderate ulcerative colitis. 

Raymond Cross, MD, is director of the Inflammatory Bowel Disease Program at the University of Maryland Medical School.

Raymond Cross:  Hi, everyone. I'm Ray Cross from the University of Maryland. I direct the IBD program there. I'm also the co-director of the Regional Advances in IBD course at Chapel Hill, North Carolina.

For those of you that were able to make the meeting and listen to my talk, thank you very much. For those of you that weren't able to make it, I wanted to summarize the key points.

I gave a talk called "Updates on Guidelines from Mild-to-Moderate UC," which were recently published by the American Gastroenterological Association. Some of the key points are as follows.

When you're thinking about types of 5-ASAs to use — most of the guideline really focuses on use of 5-ASA because that's really the most effective therapy for mild-to-moderate ulcerative colitis — in general, if you're using these drugs dose for dose, there's really no difference among the various products. That's point number 1.

Number 2, there's a heavy emphasis on once-daily dosing; the days of twice daily, 3 times, even 4-times-daily dosing are over. You can effectively transition your patients to once a day if they can tolerate the pill burden.

The third point is really a heavy emphasis as well on topical therapy, not only for patients with proctitis and proctosigmoiditis, where suppositories and enemas are considered first-line therapy, but also patients with more extensive disease. Adding topical therapy is an adjunct to oral therapy, which is shown to be more effective.

The fourth point is about optimization of therapy. Often, patients aren't optimized on 5-ASA therapy before transitioning to other therapy. After 2 to 4 weeks, you're going to assess a patient for clinical response. As long as they're not having significant worsening of disease, you're going to optimize their therapy.

For their oral medication, you're going to increase their dose to high dose or 4.8 grams a day. For those that aren't on topical therapy, you're going to add topical therapy. Importantly, you can do both. You can add topical and dose-optimize.

That also reminds me that dose is a consideration of these drugs, and there's some controversy over moderate dose or high dose. The guidelines recommend starting out at moderate dose because there isn't sufficient evidence to warrant giving all patients higher dose at the initiation of treatment.

Then, a few other points. One is on the use of oral and topical budesonide products. They are not considered first-line therapies for patients with mild-to-moderate UC. They may have a role in patients that aren't responding completely to optimize therapy that aren't sick enough to transition to immune suppressants or biologics, or you could induce remission, taper, and maintain with the 5-ASA.

A couple points about alternative treatments. The AGA wrote no recommendation on use of probiotics or curcumin. These are common products that patients use but there's insufficient evidence to advice patients to use these products. Lastly, the AGA it was fairly strong in their recommendation that fecal microbial transplant only be used in the setting of a clinical trial.

Those are the high points of my lecture. Hopefully, you'll be able to take this in after the program. If not, I hope to see you next year. Thank you very much.