AGA Publishes First Clinical Guideline for Treating Pouchitis

The standard of care following restorative proctocolectomy (removal of colon and rectum) for ulcerative colitis is ileal pouch-anal anastomosis (IPAA). With IPAA, an ileoanal pouch is created from the small intestine in lieu of using a colostomy bag. IPAA is associated with a list of complications, the most common of which is pouchitis (inflammation of the pouch lining). Close to half of individuals who undergo IPAA develop pouchitis within the first two years of surgery, and up to 80% of patients will develop it over time.

In the January issue of Gastroenterology, the American Gastroenterological Association (AGA) published the first evidence-based guideline for the management of pouchitis. A multidisciplinary panel made several recommendations to provide guidance for patients and clinicians to make informed decisions regarding the treatment of pouchitis and inflammatory pouch disorders.

The AGA delineates four types of inflammatory pouch disorders and defines them in the following ways: 1) intermittent pouchitis in which there are infrequent episodes of pouchitis symptoms that are resolved with treatment; 2) chronic antibiotic-dependent pouchitis in which the patient experiences recurrent episodes of pouchitis that respond to antibiotic treatment but return within days or weeks of stopping treatment; 3) chronic antibiotic-refractory pouchitis occurs when patients experience relapsing-remitting or continuous pouchitis symptoms that do not respond to antibiotics; and 4) with Crohn’s-like disease of the pouch, patients may have complications, such as fistulas or strictures, that develop at least 12 months after IPAA surgery.

For patients with intermittent pouchitis, the AGA suggests treatment with antibiotics, such as ciprofloxacin or metronidazole, for two to four weeks. The panelists make no recommendations in favor of or against using probiotics to prevent pouchitis in this group.

For those with chronic antibiotic-dependent pouchitis, the panel suggests using near-continuous or cyclical antibiotic therapy at the lowest effective dose. They also recommend the use of probiotics to prevent recurrent pouchitis. Advanced immunosuppressive therapies, such as Entyvio (vedolizumab), may be used instead of chronic antibiotic treatment to treat recurrent pouchitis.

For patients with chronic antibiotic-refractory pouchitis, the AGA suggests using advanced immunosuppressive therapies to treat pouchitis. Corticosteroids, such as controlled-ileal release budesonide (Entocort EC), may also be used for this group.

Lastly, for patients with Crohn’s-like disease of the pouch, suggestions from the AGA include both the use of corticosteroids and advanced immunosuppressants.

The AGA plans to update this guideline as new research develops and no later than 2027.