Figure 6
Options:
• Anti-TNF +/- thiopurine
a,b
• Vedolizumab +/- immunomodulator
c
• Thiopurine (optimize 6TGN concentrations)
• Proctocolectomy
Failure to Respond to
Prednisone
Failure to Maintain Steroid-
Induced Remission on
Thiopurine
Loss of Response to Anti-TNF
Loss of Response to
Vedolizumab
Anti-TNF, with or
without thiopurine
Vedolizumab,
with or without
immunomodulator
OR
Subtherapeutic 6TGN
(<230 pmol
6-TGN/8x10
8
RBCs)
Therapeutic 6TGN
(>230 pmol
6-TGN/8x10
8
RBCs)
Increase Dose and
Recheck Metabolites
d
Switch to Anti-TNF
or Vedolizumab
Increase dose to
300 mg q4w
No Response
Switch to Anti-TNF
with or without
Thiopurine
Subtherapeutic
Level – No or
Low Ab
Subtherapeutic
Level – High Ab
Therapeutic Level
• Increase dose
and/or decrease
interval
• Consider adding
immunomodulator
Switch within class
Switch to
vedolizumab
with or without
immunomodulator
6A
6B
6C
6D
AGA Institute Guideline on the Identification,
Assessment and Initial Medical Treatment of Ulcerative Colitis
