Ulcerative colitis (UC) is a chronic inflammatory bowel disease of complex etiology that mainly affects the colon. As there is no single pathognomonic criterion to define it, a combination of clinical, endoscopic, microbiologic and histological criteria is required to reach the final diagnosis.1 Its extension and severity vary from patient to patient, and from time to time in the same patient; hence, the definition of a clinical scenario demands to know both the severity and extension of the disease at a particular moment, according to the widely accepted “Montreal Classification”.2 The incidence and prevalence of UC have increased considerably over the last decades,3 Spain being no exception; in fact, recent data do show incidence rates that are very similar to those previously described in northern European countries.4

Currently, the different treatment methods include numerous nutritional, monitoring, follow-up, surgical, and especially pharmacological alternatives.5,6 Their application over the broad range of clinical scenarios, with such diverse individual, clinical and social circumstances, is not always easy, and this greatly justifies the need for guidelines. In fact, over the past years a number of guidelines have been published, the most notable being the ECCO guidelines,7 the BSG guidelines,8 the ACG guidelines,9 the WGO guidelines,10 the Asian-Pacific guidelines,11 and most recently, the Colombian guidelines.12 All of them are of high quality and evidence-based, but they are all based, without exception, on a relatively wide consensus process.

GETECCU (Grupo Español de Trabajo en Enfermedad de Crohn y Colitis Ulcerosa) is a 21-year-old Spanish working group on inflammatory bowel diseases, and its main goal is to improve the management of these diseases in Spain by promoting research, educational programs, and by improving care. After developing several consensus guidelines on the use of infliximab,13 TBC prevention,14 and apheresis,15 the GETECCU board decided to go a step further and start a program of evidence-based practice guidelines following the GRADE (Grades of Recommendation Assessment, Development and Evaluation) methodology16 and fulfilling AGREE (Appraisal of Guidelines, Research and Evaluation) collaboration requirements.17 This therapeutic UC guideline is the first result of this program. This report is the short form of the document; the complete document is fully available at http://dx.doi.org/10.1016/j.gastrohep.2012.11.002.

In two of the 32 clinical questions, it was not possible to reach a recommendation because the evidence available was considered of very low quality (Table 2).

The response was categorized as a strong recommendation against an intervention in three questions, with very low quality of evidence in two of them and low quality in one (Table 2).

In five questions, the response was a weak recommendation against an intervention, based all on low quality evidence.

In eight questions, there was a weak recommendation for an intervention, based three times on moderate quality evidence and five on low quality evidence.

In fourteen occasions, we found evidence to support a strong recommendation for an intervention, although high quality evidence was available only in five of them, the rest being only of moderate quality.

UC is a chronic disease with very diverse clinical scenarios, in which several different treatments are available, and with a high variability in clinical practice.23 Therefore, the need of clinical guidelines seems evident. In fact, in the last 10 years, a number of consensus guidelines have appeared,7–12 in addition to a number of expert recommendations. Although we lack direct evidence of its use in real practice, the ECCO guidelines are probably widely known, as they are very frequently cited in the literature. In addition, ECCO has a specific program of workshops to disseminate the guidelines recommendations. In fact, at least in Spain we know that clinicians treating UC patients have a very good knowledge of the ECCO statements, and a very good agreement with its recommendations has been confirmed.24 All the guidelines available are evidence-based, but all of them rely on a consensus process without a specific systematic methodology for a true Clinical Practice Guideline.

As previously mentioned, the present guideline tries to follow the recommendations of the AGREE initiative,17 using the currently widely accepted GRADE methodology.16,22 A formal comparison with available guidelines is a difficult task that exceeds the scope of this report. In our view, to follow the GRADE methodology has the advantage of a systematic approach, taking into account not only the high-quality evidence available, but also observational data, social and cost-related considerations, and the experience of the authors and reviewers.20 The final 32 recommendations and 6 algorithms proposed could help the clinician in the rather complex process of making decisions in the daily practice, in a system that is very easy to grasp.

There are, however, some limitations to be considered. First, a final guideline can only be only as good as the evidence that is available.25 We could only base our recommendation on high-quality evidence in 5 out of 32 cases, and we had to classify the quality as moderate in 12 more questions; hence, in almost 50% of the scenarios defined, the quality of the evidence is low or very low. It is clear that we need more high-quality clinical research in this field. Furthermore, there is a clear limitation in the literature available: definitions of disease activity are very different among the studies reported. This makes it especially difficult to compare the results among the different reports and populations, and the elaboration of GRADE tables has been very difficult in some of the questions, and even impossible in others. Finally, the use of a systematic methodology cannot eliminate personal bias completely. Although we have undertaken a complete and elaborate process of internal and external review, with several rounds (with more than 40 people contributing, including surgeons, nurses and patients), we cannot completely exclude this bias.

This is the short version and its full version is available online.

This guide has been possible to some extent by an unrestricted grant of MSD. MSD was not involved in any part of the development or scientific aspects of the guide.

F. Gomollón has received grants for assistance to scientific meetings from Abbott and MSD. He has also received consultancy fees from FAES-FARMA, Abbott and MSD. He has also received research support from MSD.

S. García-López has received grants for assistance to scientific meetings from Abbott, MSD, FAES-FARMA, Ferring and Shire. He has also received consultancy fees from Abbott and MSD.

B. Sicilia has received grants for assistance to scientific meetings from Abbott, MSD, FAES-FARMA, Ferring y Shire.

Javier P Gisbert has received grants for assistance to scientific meetings from Abbott and MSD. He has also received consultancy fees from FAES-FARMA, Abbott and MSD.

Joaquin Hinojosa has received grants for assistance to scientific meetings from Abbott and MSD. He has also received consultancy fees from FAES-FARMA, Abbott and MSD.