Drug Update · Gastroenterology

AGA Updates Ulcerative Colitis Guidelines: Recommends Multiple Therapies

August 28, 2026

Guideline name

AGA Living Clinical Practice Guideline on Pharmacological Management of Moderate-to-Severe Ulcerative Colitis

Recommendations

14 recommendations

Target population

Adult outpatients with moderate-to-severe ulcerative colitis

Key recommended agents

infliximab; golimumab; vedolizumab; tofacitinib; upadacitinib; ustekinumab; ozanimod; etrasimod; risankizumab; guselkumab

Agents suggested over no treatment

adalimumab; filgotinib; mirikizumab

Clinical Perspective

This guideline affects gastroenterologists and clinicians managing adult outpatients with moderate-to-severe ulcerative colitis by providing a consolidated set of recommendations for multiple advanced therapies and immunomodulator strategies ^[1]. The guideline supports selection among multiple biologic classes, JAK inhibitors, S1P modulators, and IL-23 antagonists with examples of higher-, intermediate-, and lower-efficacy medications for therapy-naïve and previously treated patients, and provides guidance on combination therapy, withdrawal considerations after at least 6 months of corticosteroid-free remission, and stopping 5-aminosalicylates after escalation ^[1]. What is the optimal sequencing or combination of these therapies to maximize long-term disease control and safety in defined patient subgroups?

Dr. Sanjay Iyer, MBBS, MD (General Medicine), DM (Gastroenterology) · Gastroenterology

The American Gastroenterological Association (AGA) published a living clinical practice guideline on pharmacological management of moderate-to-severe ulcerative colitis that made 14 recommendations covering biologics, JAK inhibitors, S1P modulators, and IL-23 agents in adult outpatients. The guideline recommends the use of infliximab, golimumab, vedolizumab, tofacitinib, upadacitinib, ustekinumab, ozanimod, etrasimod, risankizumab, and guselkumab and suggests the use of adalimumab, filgotinib, and mirikizumab over no treatment ^[1].

Clinical Context

The AGA living guideline is intended to support practitioners in the pharmacological management of adult outpatients with moderate-to-severe ulcerative colitis and was developed by a multidisciplinary panel using the GRADE framework to prioritize clinical questions and synthesize evidence ^[1]. The panel characterized available agents as “advanced therapies” and provided graded recommendations that include tumor necrosis factor (TNF)-α antagonists, JAK inhibitors, interleukin-23 antagonists, and sphingosine-1-phosphate (S1P) receptor modulators by naming specific drugs such as infliximab, golimumab, vedolizumab, tofacitinib, upadacitinib, risankizumab, guselkumab, ozanimod, and etrasimod ^[1]. The guideline also proposed implementation considerations and identified knowledge gaps and areas for future research to guide clinicians managing moderate-to-severe disease ^[1].

Key Findings

The AGA guideline panel made 14 recommendations for adult outpatients with moderate-to-severe ulcerative colitis, and recommends the use of infliximab, golimumab, vedolizumab, tofacitinib, upadacitinib, ustekinumab, ozanimod, etrasimod, risankizumab, and guselkumab; it suggests the use of adalimumab, filgotinib, and mirikizumab over no treatment ^[1].
For patients naïve to advanced therapies, the AGA suggests using a higher-efficacy medication (eg, infliximab, vedolizumab, ozanimod, etrasimod, upadacitinib, risankizumab, and guselkumab) or an intermediate-efficacy medication (eg, golimumab, ustekinumab, tofacitinib, filgotinib, and mirikizumab) rather than a lower-efficacy medication (eg, adalimumab) ^[1].
In patients previously exposed to 1 or more advanced therapies, particularly TNF-α antagonists, the AGA suggests using a higher-efficacy medication (eg, tofacitinib, upadacitinib, and ustekinumab) or an intermediate-efficacy medication (eg, filgotinib, mirikizumab, risankizumab, and guselkumab) rather than a lower-efficacy medication (eg, adalimumab, vedolizumab, ozanimod, and etrasimod) ^[1].
The AGA suggests against thiopurine monotherapy for induction of remission but suggests thiopurine monotherapy over no treatment for maintenance of (typically corticosteroid-induced) remission, and suggests against methotrexate monotherapy for induction or maintenance of remission ^[1].
The AGA suggests the use of infliximab, adalimumab, and golimumab in combination with an immunomodulator over corresponding monotherapy, while making no recommendation for or against combining non-TNF biologics with immunomodulators versus non-TNF biologic monotherapy ^[1].
For patients in corticosteroid-free clinical remission for at least 6 months on combination therapy of TNF antagonists and an immunomodulator, the AGA suggests against withdrawal of TNF antagonists, but makes no recommendation for or against withdrawing immunomodulators; the guideline also suggests stopping 5-aminosalicylates in patients who have escalated to immunomodulators or advanced therapies and recommends earlier use of advanced therapies and/or immunomodulator therapy rather than a gradual step-up after failure of 5-aminosalicylates ^[1].

Safety & Tolerability

Prior to initiating SIMPONI ARIA (golimumab) and periodically during therapy, evaluate patients for active tuberculosis and test for latent infection ^[2].
Prior to initiating SIMPONI ARIA (golimumab), test patients for hepatitis B viral infection ^[2].

Study Design

The document is the AGA Living Clinical Practice Guideline on Pharmacological Management of Moderate-to-Severe Ulcerative Colitis, developed by a multidisciplinary guideline panel and methodologists using the GRADE framework to prioritize clinical questions, synthesize evidence, and issue 14 recommendations for adult outpatients with moderate-to-severe UC; the panel reported conflicts of interest and proposed implementation considerations and areas for future research ^[1].

FAQ

Q1 What changed in the AGA guideline?

The AGA panel published a living guideline comprising 14 recommendations for pharmacological management of adult outpatients with moderate-to-severe ulcerative colitis. The guideline explicitly names multiple advanced therapies recommended for use, including infliximab, golimumab, vedolizumab, tofacitinib, upadacitinib, ustekinumab, ozanimod, etrasimod, risankizumab, and guselkumab, and suggests adalimumab, filgotinib, and mirikizumab over no treatment; it also issues recommendations on combination therapy with immunomodulators, stopping 5-aminosalicylates after escalation, and early use of advanced therapies versus gradual step-up after 5-ASA failure.

Q2 Who is affected by the guideline?

The guideline is intended to support practitioners and clinicians managing adult outpatients with moderate-to-severe ulcerative colitis. It provides recommendation frameworks for therapy-naïve patients and for patients previously exposed to one or more advanced therapies, including considerations for combination therapy, withdrawal of TNF antagonists after sustained corticosteroid-free remission, and stopping 5-aminosalicylates after escalation.

Q3 What was recommended before this guideline?

[Information] was not available in the provided source excerpts.

Q4 When does the guideline take effect?

[Information] was not available in the provided source excerpts.

AGA Updates Ulcerative Colitis Guidelines: Recommends Multiple Therapies

Direct Clinical Takeaway & Evidence Summary

AGA Updates Ulcerative Colitis Guidelines: Recommends Multiple Therapies

Clinical Perspective

Clinical Context

Key Findings

Safety & Tolerability

Study Design

FAQ

References

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