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HIBD Horizon

Part 2 · Getting treatment today · 8/22

UC: which treatment for which situation?

How well treatments work depending on the extent and severity of the disease, and in special cases.

Which treatment works best, and for what?Each situation has its treatments of choice. The levels summarise the European guidelines (ECCO), the large comparisons of studies and the key trials, cited under each card.
Strongest evidence of efficacy
Effective, proven in trials
More limited evidence or supporting role

Proctitis (rectum only)

the most limited form

Strongest evidence of efficacy
Mesalazine suppositoriesPentasa, Fivasa, Rowasa, Osperzo
Effective, proven in trials
Mesalazine tabletsin additionLocal steroidsfoams, enemas

For the rectum, local treatment works better than tablets alone, and the two can be combined if that is not enough.

Sources : ECCO UC 2022

Mild to moderate UC

left colon or extensive

Strongest evidence of efficacy
Mesalazinetablets + enemas
Effective, proven in trials
BudesonideCortimentConventional steroidsshort course, if other treatment fails

A good dose of mesalazine, every day, is enough for many patients. Steroids put out the flare but are not a maintenance treatment.

Sources : ECCO UC 2022

Moderate to severe UC

when mesalazine is no longer enough

Strongest evidence of efficacy
UpadacitinibRinvoqInfliximabRemicadeRisankizumabSkyriziGuselkumabTremfya
Effective, proven in trials
MirikizumabOmvohVedolizumabEntyvioUstekinumabStelaraS1PZeposia, VelsipityOther JAKsXeljanz, JyselecaGolimumabSimponi
A little less effective in the comparisons
AdalimumabHumira
The figures from the trials

Rinvoq: 26% in remission at 8 weeks versus 5% on placebo (U-ACHIEVE, about half of the patients had already failed a biologic).

Head to head: remission at 1 year in 31% on Entyvio versus 23% on Humira (VARSITY).

Rinvoq often comes out on top in the large comparisons, but the differences remain modest. JAK inhibitors (Rinvoq, Xeljanz, Jyseleca) require precautions after age 65, in smokers and in people with heart risk.

Sources : AGA 2024 summary; network meta-analyses 2022-2024; U-ACHIEVE, Lancet 2022; VARSITY, NEJM 2019

Very severe flare

in hospital, it is an emergency

First
Intravenous steroidsfor 3 to 5 days
If that fails
InfliximabRemicadeCiclosporinjust as effective
As a last resort
Surgerya real treatment, not a failure
The figures from the trials

Intravenous steroids: about 2 patients in 3 respond.

If they are not enough, infliximab and ciclosporin are on a par. On a very demanding endpoint (steroid-free remission at 3 months, with no relapse or operation), failure affected 54% versus 60%, a non-significant difference (CYSIF).

Don't wait: with 6 or more bloody stools a day plus fever, a racing heart, marked paleness or intense fatigue, seek urgent medical care.

Sources : ECCO UC 2022; Turner, Clin Gastroenterol Hepatol 2007; CYSIF, Lancet 2012

Pouchitis

inflammation after an ileoanal pouch

Strongest evidence of efficacy
Antibioticsciprofloxacin, metronidazole
Effective, proven in trials
VedolizumabEntyvio, if it resists antibiotics
More limited evidence or supporting role
Probioticsprevention, limited evidence
The figures from the trials

Entyvio in chronic pouchitis that resists antibiotics: 31% in remission at 14 weeks versus 10% on placebo (EARNEST).

Most cases of acute pouchitis heal with two weeks of antibiotics.

Sources : ECCO guidelines; EARNEST, NEJM 2023

Signs outside the bowel

Crohn's and UC: joints, skin, eyes

Strongest evidence of efficacy
Anti-TNFthe most evidence
Effective, proven in trials
Other biologics and JAK inhibitorsdepending on the organ affected, with the specialist

Calming the bowel often calms pain in the large joints and skin nodules, but not always the spine, the eyes or the liver, which have their own follow-up. Entyvio acts mainly in the bowel.

Sources : ECCO 2024, extra-intestinal manifestations

Read this before comparingThis is not a personal ranking. The percentages come from trials in selected patients, often compared with a placebo: in real life, and after several treatments, they are often lower. The differences between treatments are often small, and they were measured in different studies. The best treatment for you depends on where the disease is, your past treatments, your other health problems and your plans. A “lower-ranked” treatment may be the right one for you. Some figures come from small trials or recent congresses and may change.