For our first #GUTBlog, Professor El-Omar has invited Dr Chris Lamb and Dr Barney Hawthorne who are together the first and senior author of the British Society of Gastroenterology guidelines on the management of inflammatory bowel disease in adults published in Gut.

Dr Chris Lamb is a Consultant Gastroenterologist at the Newcastle upon Tyne Hospitals NHS Foundation Trust and leads a research group in IBD at Newcastle University as a Clinical Intermediate Fellow. Dr Barney Hawthorne is a Consultant Gastroenterologist at the University Hospital of Wales, Cardiff.

“The new British Society of Gastroenterology guidelines for management of inflammatory bowel disease in adults have recently been published in Gut.

What do the new BSG IBD Guidelines provide?

They are freely available and form a comprehensive guide for IBD teams to support high quality care. The document is designed to be practical and user-friendly in everyday outpatient or inpatient management. An interactive contents page and extensive hyperlinks allow easy navigation to specific areas of information.

Drug management of IBD is considered including up to date literature regarding anti-TNF therapy (including biosimilars), vedolizumab, ustekinumab, tofacitinib, thiopurines, methotrexate, 5ASAs and steroids. The guideline also covers non-pharmacological management including dietary therapy, pre-, peri and post-operative medical management, pain, fatigue and psychology.

There is a focus on patient safety including pre-immunosuppression tests, use of vaccination, management of common side effects of therapy, the use of therapeutic drug monitoring and the prevention and management of osteoporosis in IBD.

Guidance is given regarding communication and shared management between primary and secondary care as well as adolescent transition care.

Who contributed?

The guidelines were developed over more than 3 years by a group of 29 authors, who also contributed to an eDelphi consensus process which involved a total of 81 experts in IBD from across the UK. All major stakeholders in UK IBD management were represented including the British Society of Gastroenterology (BSG), the Association of Coloproctology of Great Britain and Ireland (ACPGBI), the Royal College of Nursing (RCN), the British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN), the British Dietetic Association (BDA), the British Society of Gastrointestinal and Abdominal Radiology (BSGAR) and the Primary Care Society for Gastroenterology (PCSG). Patient representation was included at all stages of the guideline development through close collaboration with Crohn’s & Colitis UK.

How was the quality of the guidance ensured?

The guideline development followed a NICE accredited process conforming to the internationally recognised process called GRADE methodology. Over 400, many multifaceted, clinical questions or scenarios that IBD patients and clinicians face in clinical practice were considered in order to inform a literature search that returned over 88,000 papers for systematic review and incorporation/refinement into a total of 135 evidence-based “graded” recommendations and 33 good practice recommendations. Each statement has the strength of recommendation, and the quality of the evidence included. In addition the level of agreement at the end of the Delphi process is recorded (all statements had to have an agreement over 80%).

The final document cites 1,289 papers arranged around four broad categories of “ulcerative colitis”, “Crohn’s disease”, “Common disease considerations” relevant to both conditions and “Service delivery”. This final section aligns closely with the new UK IBD Standards, recently published in Frontline Gastroenterology. The guidelines discuss the important evidence and expert opinion regarding multidisciplinary team management of ulcerative colitis and Crohn’s disease, the Standards describe team composition, service design, operational delivery and key performance indicators. The guidelines also complement the 2018 British Surgical IBD guidelines published in Colorectal Disease.

How did the document identify current and future needs?

Finally the guideline considers where high quality evidence is lacking in order to inform management of IBD. Working closely with Crohn’s & Colitis UK feedback was received from IBD patients, family and friends in the form of nearly 2400 electronic survey responses. This research prioritisation process complements the James Lind Alliance findings highlighting important areas of research to patients including the pathogenesis and management of fatigue, chemoprevention and dysplasia surveillance in colitis, evidence-based strategies to implement precision medicine, the impact of ‘treat to target’ in routine clinical practice, defining patient reported outcomes, biomarkers of treatment response, the microbiome and faecal microbial transplantation.

We hope the guideline and research prioritisation exercise can support current every day, high quality, best personalised care, and in the future will inform government and research funding bodies to finance and encourage important IBD research.”