12December2017

The newly revised ECCO/ESPGHAN Paediatric UC Guideline

Richard Russell, P-ECCO Member

Richard RussellRichard Russell  ©  ECCO

The revision of the Paediatric UC Guideline for children has been carried out jointly by the ESPGHAN Porto IBD group and ECCO. This revised guideline has updated the previous separate guidelines on Acute Severe UC and Ambulatory UC [1,2] and combined them into one document. The guideline was developed on the basis of an intensive literature search and careful evidence grading; the Oxford levels of evidence were used for the latter purpose after it became clear that the guideline was being developed too soon for the use of GRADE methodology. A summary of all the evidence assimilated during the guideline development will be published as supplementary tables so that others can benefit from the intensive search without having to redo the work.

A lot has changed in the 5 years since the last guidelines were published but some core concepts remain in the new guideline. The frequent assessment and monitoring of patients with Acute Severe UC using the PUCAI to assess disease activity (≥65 remains the definition of ASC) has become established as the cornerstone of practice since the publication of the first guideline, with adjustment of therapy based on daily values collected during a patient’s stay. At day 3 of admission, response to steroids should be assessed and if poor response screening for 2nd line agents should begin, then with initiation of rescue therapy for non-responders at day 5.  The acceptance and use of rescue therapy have increased significantly since the initial guideline, and the new guideline recommends that infliximab is used as the preferred rescue therapy over calcineurin inhibitors, all other factors being equal.

In the revised guideline there is unsurprisingly more emphasis on faecal calprotectin and its use to monitor patients in the outpatient setting and to define which patients will benefit from endoscopic reassessment. The changing treatment targets are reflected in the guidance, with an emphasis on patients achieving clinical (PUCAI <10) and biochemical remission (represented by calprotectin), with clarification of mucosal healing by endoscopy if there is any doubt in the previous patient measurements. To summarise these issues and reflect current practice, a treat-to-target algorithm is contained within the new guideline.

Although the new biologic drugs used in adult practice have not yet been licensed for use in paediatric patients, vedolizumab and golimumab do get a mention, with suggestions on how they should be used at present while recognising that it will probably not be until the guideline is next revised that the licensing trials will have been performed! Therapeutic drug monitoring is an area which has become well established in clinical practice since the initial guideline was published. The new guideline gives recommendations on target levels when patients are on anti-TNF therapies and guidance on how to adjust therapy based on the result of the monitoring. The role of intensified treatment early in the course of especially Acute Severe UC remains an area of ongoing work in paediatric UC and the guideline acknowledges this.

Previously no specific guidance was recommended for thromboprophylaxis for paediatric patients with Acute Severe UC but the new guidance, while not making a universal recommendation, recommends its use in certain patients based on the number of risk factors for thrombosis present. Low molecular weight heparin is recommended for patients over the age of 12 if one risk factor for thrombosis is present, whereas in children under 12 its use is recommended in the presence of two risk factors, given the very low absolute risk of thrombosis in this age group. While this is an advance in management, the higher predisposition of children to have central thrombosis rather than the deep vein thrombosis more commonly encountered in adults will mean that thrombosis remains a challenging issue for paediatricians.

The guidelines will be published in full in early 2018 and will be presented at the next ECCO Congress 2018 in Vienna. Dissemination of the established and the new guidance will be critical in ensuring that good practice is in place for all patients with paediatric UC.

 

References 

1. Turner D, Travis SP, Griffiths AM, et al. Consensus for managing acute severe ulcerative colitis in children: A systematic review and joint statement from ECCO, ESPGHAN, and the Porto IBD Working Group of ESPGHAN. Am J Gastroenterol. 2011;106:574–88.

2. Turner D, Levine A, Escher JC, et al. Management of pediatric ulcerative colitis: Joint ECCO and ESPGHAN evidence-based consensus guidelines. J Pediatr Gastroenterol Nutr. 2012;55:340–61.

Posted in ECCO News, Committee News, P-ECCO, Volume 12, Issue 4

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