Second Korean Guideline for the Management of Ulcerative Colitis

Chang Hwan Choi; Won Moon; You Sun Kim; Eun Soo Kim; Bo-In Lee; Yunho Jung; Yong Sik Yoon; Heeyoung Lee; Dong Il Park; Dong Soo Han

doi:10.4166/kjg.2017.69.1.1

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Choi, Moon, Kim, Kim, Lee, Jung, Yoon, Lee, Park, and Han: Second Korean Guideline for the Management of Ulcerative Colitis

Review Article

Korean J Gastroenterol 2017;69(1):1-28.

Published online: 4 October 2017

DOI: https://doi.org/10.4166/kjg.2017.69.1.1

Second Korean Guideline for the Management of Ulcerative Colitis

Chang Hwan Choi, Won Moon¹, You Sun Kim², Eun Soo Kim³, Bo-In Lee⁴, Yunho Jung⁵, Yong Sik Yoon⁶, Heeyoung Lee⁷, Dong Il Park⁸, Dong Soo Han⁹

Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea

¹Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea

²Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea

³Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea

⁴Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

⁵Division of Gastroenterology, Department of Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea

⁶Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea

⁷Center for Preventive Medicine and Public Health, Seoul National University Bundang Hospital, Seongnam, Korea

⁸Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea

⁹Department of Internal Medicine, Hanyang University College of Medicine, Guri, Korea

Correspondence to: Dong Soo Han, Department of Internal Medicine, Hanyang University Guri Hospital, 153 Gyeongchun-ro, Guri 11923, Korea. Tel: +82-31-560-2226, Fax: +82-31-555-2998, E-mail: hands@hanyang.ac.kr

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Ulcerative colitis (UC) is a chronic inflammatory bowel disorder characterized by a relapsing and remitting course. The direct and indirect costs of the treatment of UC are high, and the quality of life of patients is reduced, especially during exacerbation of the disease. The incidence and prevalence of UC in Korea are still lower than those of Western countries, but have been rapidly increasing during the past decades. Various medical and surgical therapies, including biologics, are currently used for the management of UC. However, many challenging issues exist, which sometimes lead to differences in practice between clinicians. Therefore, the Inflammatory Bowel Disease Study Group of the Korean Association for the Study of Intestinal Diseases established the first Korean guideline for the management of UC in 2012. This is an update of the first guideline. It was generally made by the adaptation of several foreign guidelines as was the first edition, and encompasses treatment of active colitis, maintenance of remission, and indication of surgery for UC. The specific recommendations are presented with the quality of evidence and classification of recommendations.

Keywords: Colitis, ulcerative, Inflammatory bowel disease, Management, Guideline

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Table 1.

Nine Guidelines Selected for Adaptation^13–21

No.	Title	Country	Journal	Year	Volume/Page
1	Ulcerative colitis: management in adults, children and young people	UK	National Clinical	2013
			Guideline Centre
2	Treatment of hospitalized adult patients with severe ulcerative colitis: Toronto consensus statements	Canada	American Journal of Gastroenterology	2012	107/179–194
3	Clinical practice guidelines for the medical management of nonhospitalized ulcerative colitis: the Toronto consensus	Canada	Gastroenterology	2015	148/1035–1058
4	The London position statement of the World Congress of Gastroenterology on Biological Therapy for IBD with the European Crohn's and Colitis Organization: when to start, when to stop, which drug to choose, and how to predict response?	World Congress of Gastroenterology	American Journal of Gastroenterology	2011	106/199–212
5	The London position statement of the World Congress of Gastroenterology on Biological Therapy for IBD with the European Crohn's and Colitis Organisation: safety	World Congress of Gastroenterology	American Journal of Gastroenterology	2011	106/1594–1602
5	Second European evidence-based consensus on the diagnosis and management of ulcerative colitis part 2: current management	EU	Journal of Crohn's and Colitis	2012	6/991–1030
7	Therapeutic guidelines on ulcerative colitis: a GRADE methodology based effort of GETECCU	Spain	Gastroenterologia y Hepatologia	2013	36/104–114
8	Guidelines for the management of inflammatory bowel disease in adults	UK	Gut	2011	60/571–607
9	The Italian Society of Gastroenterology (SIGE) and the Italian Group for the Study of Inflammatory Bowel Disease (IG-IBD) Clinical Practice Guidelines: The use of tumor necrosis factor-alpha antagonist therapy in inflammatory bowel disease	Italy	Digestive and Liver Disease	2011	43/1–20.

Table 2.

Definitions or Implications of the Levels of Evidence and Recommendations

Level	Definitions/implications
Quality of evidence
High	We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate	We are moderately confident about the effect estimate: the true effect is most likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low	Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low	We have very little confidence in the effect estimate: the true effect is most likely to be substantially different from the estimate of the effect.
Classification of recommendations
Strong	Most patients should receive the recommended course of action.
Weak	Clinicians should recognize that different choices would be appropriate for different patients and that they must help patients to arrive at a management decision consistent with their values and preferences.

Table 3.

Truelove and Witts' Score for Clinical Severity of Ulcerative Colitis^11,27

	Mild ^a	Moderate	Severe ^b
(1) Frequency of defection	4 times or less	Intermediate between mild and severe	6 times or more
(2) Bloody stool	(−) or (+)		(+++)
(3) Fever ^c	Absent		37.5° C or higher
(4) Tachycardia ^d	Absent		90/min or more
(5) Anemia	Absent		Hb 10 g/dL or less
(6) ESR	Normal		30 mm/h or more

Hb, hemoglobin; ESR, erythrocyte sedimentation rate.

^a Rated as “mild” when all 6 criteria are satisfied.

^b Rated as “severe” when criteria (1) and (2), and either of systemic symptoms (3) and (4) are satisfied, and at least 4 of the 6 criteria are satisfied.

^c Fever: mean evening temperature of >37.5 C, or a temperature of ≥37.8 C at least 2 of 4 days.

^d Tachycardia: mean pulse rate of >90/min.

Table 4.

Delivery System for 5-ASA⁸

5-ASA	Delivery system
Azo-bond
Sulfasalazine (500 mg/tablet)	Sulfapyridine carrier
Olsalazine (250 mg/capsule)	5-ASA dimer
Balsalazide (750 mg/capsule)	4-Amino-benzoyl-β-alanine
Controlled release
Pentasa^® (500 mg or 1000 mg/tablet)	Ethylcellulose-coated microgranules
pH 7-dependent
Asacol^® (400 mg/tablet)	Eudragit-S coating, dissolves at pH 7
pH 6-dependent
Salofalk^® (250 mg/tablet)	Eudragit-L coating, dissolves at pH 6
Composite (multimatrix, 1200 mg/tablet) Mezavant^® (EU)	Eudragit-S coating of hydrophilic polymer with some 5-ASA and lipophilic excipients encapsulating 5-ASA
Lialda^® (US)

5-ASA, 5-aminosalicylic acid.

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