Letter: real‐life management of new onset ulcerative colitis and proctitis

Abstract

We read with interest the study of Richter et al. about the treatment of new onset ulcerative colitis (UC) in a large, American, insurance database cohort.1 The study provides robust data on how UC is managed in real life. As expected, most patients with UC were initially managed with oral 5-ASA, whereas the majority of those with ulcerative proctitis (UP) were treated with topical mesalazine. Optimistically, the authors concluded that care of these patients appears consistent with treatment guidelines. However, we believe that there are some issues that should be carefully addressed. First, 5-ASA combination therapy (oral and rectal) was prescribed in only a small proportion of patients (<20%). As stated in the consensus of the European Crohn's and Colitis Organization (ECCO),2 5-ASA combination therapy should be the treatment of choice for those patients with left-sided or extensive UC with mild-to-moderate activity. Combination therapy has proven to achieve more rapid clinical improvement than monotherapy, and some controlled studies suggest even significantly higher remission rates.3 Moreover, topical 5-ASA (suppositories or enemas) was prescribed as monotherapy in only half of the patients, whereas oral 5-ASA was used as monotherapy in almost 20%. It is known that 5-ASAs achieve the lowest mucosal concentrations at the rectum when administered orally, and both ECCO and the American College of Gastroenterology recommend topical therapy for distal forms of colitis, mainly in UP.2, 4 Second, a large proportion of patients did not follow maintenance therapy after induction of remission. In fact, 40% of those UC patients who began oral 5-ASA, 70% of UP patients who were initially treated with mesalazine suppositories, and even 40–50% of those patients who began oral or systemic glucocorticsteroids, did not receive any medication for the rest of the year. This appears to be of great relevance given that UC is a chronic relapsing disease, even more so in patients with extensive UC or those who required systemic glucocorticosteroids.5, 6 Furthermore, deep control of the inflammatory activity seems to be the key to prevent dysplasia in a long-term basis.7 Finally, we would like to emphasise that lack of adherence to clinical guideline recommendations seems to be relatively common in real life. Thus, a cross-sectional survey was recently conducted in Spain to assess the adherence to the ECCO guidelines on mild-to-moderate UC.8 We surveyed gastroenterologists specialised in inflammatory bowel disease (GSIBDs) and general gastroenterologists (GGs). Although agreement with the guidelines was, in general, relatively high, remarkably discrepancies included that only 25% of the GGs used the combination of oral and topical 5-ASA for treating extensive UC vs. 45% of the GISBDs. In addition, indefinite treatment with 5-ASA was prescribed by only 26% of the GGs vs. 41% of the GSIBDs. Declaration of personal and funding interests: None.