Ulcerative colitis
Also known as: IBD · inflammatory bowel disease · UC
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ACG Clinical Guideline Update: Ulcerative Colitis in Adults
American College of Gastroenterology (ACG) · 2025 · 2025 update
This updated ACG guideline covers diagnosis, assessment and therapeutic and surgical management of ulcerative colitis in adults, combining GRADE-based recommendations with expert consensus statements.
- The update addresses induction and maintenance of remission, positioning of advanced therapies, management of acute severe disease and surgical considerations. source
- It represents the official practice recommendations of the American College of Gastroenterology for adults with ulcerative colitis. source
ECCO Guidelines on Therapeutics in Ulcerative Colitis: Medical Treatment
ECCO (European Crohn's and Colitis Organisation) · 2022
ECCO's guideline summarises recommended drug treatment for adults with ulcerative colitis, from mild disease through moderate-to-severe disease.
US vs EU key differences
- Version currency differs sharply: the ACG update dates to 2025 and addresses newer oral agents such as upadacitinib maintenance, while the ECCO therapeutics guideline dates to 2022 and covers tofacitinib as the only JAK inhibitor. source
- The ACG update endorses an explicit endoscopic treatment target, recommending treatment to endoscopic improvement (Mayo endoscopic subscore 0 or 1) to reduce hospitalisation and surgery. source
- 5-ASA positioning differs: ECCO gives strong recommendations for oral 5-ASA at least 2 g/day plus topical rectal 5-ASA at least 1 g/day in mild-to-moderate disease, whereas the 2025 ACG update suggests against continuing 5-ASA for added efficacy once a biologic or JAK inhibitor is used for induction. source
- The ACG update recommends testing for Clostridioides difficile in every patient with suspected ulcerative colitis or a flare, and using faecal calprotectin to assess treatment response and suspected relapse. source
What changed recently
- US2019 → 2025 update2025-06-01
This update revises the 2019 ACG ulcerative colitis guideline with five years of new trial evidence, expanding and repositioning advanced therapies for moderate-to-severe disease. Etrasimod, an S1P receptor modulator, is newly recommended for both induction and maintenance of remission.
source ↗curation confidence 90% - EU2017 → 20222022-01-01
The 2022 ECCO therapeutics guideline drops methotrexate for maintenance after the MERIT-UC trial showed no benefit over placebo, and incorporates evidence for vedolizumab, ustekinumab and tofacitinib. Rigid treatment hierarchies were moved out of the recommendations into the supporting text so new agents can be slotted in.
See the full update feed for changes across every system.