This year, experts from ECCO and ESPGHAN came together to revise and update the guideline for the treatment and management of paediatric patients with ulcerative colitis. The guideline has been drawn out in an attempt to standardise and better treatment for ulcerative colitis patients all over the world.

The worldwide prevalence rate of inflammatory bowel disease is reported in the range of 6-30 per 100,000 individuals. To manage it, the European Crohn's and Colitis Organization (ECCO) and the European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) published guidelines which were updated this year. In this article, we will discuss these guideline updates.

ECCO-ESPGHAN guidelines

The ECCO-ESPGHAN guidelines for the management of pediatric ulcerative colitis were released after doing a thorough systematic review (SR) of the literature and the consensus process. These guidelines are divided into two parts- ambulatory care, and acute severe colitis.

Updates in part 1: Management of Pediatric Ulcerative Colitis- Ambulatory care

The following updates with respect to the management of pediatric ulcerative are present in part 1 of the ECCO-ESPHAGAN guidelines:

• If a child in remission (Paediatric Ulcerative Colitis Activity Index, PUCAI <10) has high calprotectin levels, then the endoscopic evaluation should be done to find the underlying endoscopic disease or the physician should change the treatment. This is recommended as 20% of children in PUCAI have endoscopic diseases.
• The updated guidelines recommend the use of golimumab and vedolizumab for treatment of ulcerative colitis.
• Golimumab should be given only to patients who are intolerant to infliximab or who have stopped responding to infliximab. The recommended induction dose of Golimumab for children weighing ≥45 kg is 200 mg at week 0 and 100 mg at week 2. For children weighing <45 kg, the induction dose is 115 mg at week 0 and 60mg at week 2. The maintenance dose is 100 mg, q4w for children ≥45 kg and 60 mg, q4w if the weight is <45 kg.
• Vedolizumab is recommended as a second-line therapy after anti-TNF failure in active or steroid-dependent patients. The standard Vedolizumab dosing is recommended in children, 5 mg/kg up to 300 mg per dose at weeks 0, 2, 6 followed by every 8 weeks). For children weighing less than 30 kg, the dose should be calculated based on body surface area.
• The guidelines strongly recommend the practice of therapeutic drug monitoring for determining adherence to treatment.
• As per the new guidelines, thromboembolism prophylaxis should be given routinely. This was not recommended earlier.
• The guideline also discourages routine use of granulocyte/monocyte apheresis, faecal microbiota transplantation, and antibiotics for induction or maintenance of remission.

Apart from these updates, the guidelines include inflammatory bowel diseases (IBD) classes and discussion on IBD unclassified.

Updates in part 2: Management of Pediatric Ulcerative Colitis - Acute severe colitis

There are no major updates in the management of acute severe pediatric colitis cases. The new updates in the revised guidelines include:

• The new guidelines emphasise on the practice of therapeutic drug monitoring the use of thrombotic prophylaxis.
• As per the new guidelines, sequential therapy should be started only when an undetectable amount of the previous drug has been documented. If sequential therapy is given, then Pneumocystis jiroveci pneumonia (PJP) prophylaxis is recommended especially in triple immunosuppressive treatment.
• The sequential therapy with calcineurin inhibitors (before or after infliximab) must be given after the steroids are weaned out completely as concomitant administration of steroid may increase the risk of infection.

The updates in the guidelines are based on latest clinical trials and review of the literature. They have been provided with an aim to help practitioners at all levels, however they do stress that each patient is unique and therefore the recommendations should be used in conjunction with local practice patterns.