Long-term Outcome of Patients With Acute Severe Ulcerative Colitis Responding to Intravenous Steroids

Robert Salameh; Julien Kirchgesner; Matthieu Allez; Franck Carbonnel; Antoine Meyer; Jean-Marc Gornet; Laurent Beaugerie; Aurelien Amiot

Disclosures

Aliment Pharmacol Ther. 2020;51(11):1096-1104. 

In This Article

Abstract and Introduction

Abstract

Background: The long-term outcome of patients with acute severe ulcerative colitis (ASUC) responding to intravenous steroids (IVS) has been poorly reported.

Aims: To assess relapse-free survival in patients with ASUC responding to IVS.

Methods: Between January 2006 and December 2017, 142 consecutive patients with ASUC (according to modified Truelove-and-Witts criteria) responding to IVS were included in this multicentre retrospective study. Relapse was defined by a partial Mayo Clinic score >4 and/or the need for another maintenance therapy.

Results: Among the 142 included patients (100 naïve of immunomodulator and/or biological agent) hospitalised for ASUC, 59 (41.5%) were treated at discharge with 5-aminosalicylic acid, 60 (42%) with immunomodulators, 18 (13%) with anti-tumour necrosis factor (TNF) agents and 5 (3.5%) with vedolizumab. After a median follow-up of 4.8 (2.6–7.3) years, 90 (63.4%) had relapsed and 12 (8.5%) had required colectomy. The probabilities of relapse-free survival were 58%, 48% and 40% at 1, 2 and 5 years respectively. The multivariate analysis demonstrated that patients with <6 liquid stools per day at day 3 (hazard ratio 0.56, 95%CI [0.34–0.91]), a partial Mayo Clinic score <2 at day 5 (0.41 [0.21–0.80]) and anti-TNF maintenance therapy (0.37 [0.16–0.87]) were less likely to relapse. The probabilities of colectomy-free survival were 96%, 95% and 91% at 1, 2 and 5 years respectively.

Conclusion: Despite a high relapse rate, patients with ASUC responding to IVS had a low rate of colectomy after 5 years of follow-up. Early response to IVS and maintenance therapy with biological agents were associated with a lower rate of relapse.

Introduction

Ulcerative colitis (UC) is a chronic and disabling disease characterised by a sequence of flares and remission.[1] In up to 25% of cases, patients with UC will develop a severe exacerbation of the disease and require hospitalisation and intravenous steroids (IVS).[2] Acute severe ulcerative colitis (ASUC) is a life-threatening condition with an estimated risk of mortality of 1%-2% and emergency colectomy of 30%.[3,4]

Management of ASUC relies on a multidisciplinary approach with gastroenterologists and surgeons and requires hospitalisation for intensive medical therapy.[5] IVS therapy remains the mainstream treatment for patients with ASUC together with fluid and electrolyte resuscitation, nutritional support and thromboprophylaxis.[6] Since the 1970s, the effectiveness of this intensive medical therapy has not changed over time, with an overall response rate of 67%.[4]

Most of the studies have focussed on patients refractory to IVS, investigating the efficacy of either anti-TNF agents or calcineurin inhibitors.[7–11] Indeed, very few studies have reported the long-term outcome of patients with ASUC responding to IVS, especially with respect to the associated maintenance therapy.[12,13] Recently, the European Crohn's and Colitis Organization (ECCO) has stated with a low level of evidence that thiopurine-naïve patients with severe colitis responding to steroids should be treated appropriately with thiopurines or calcineurin inhibitors, while thiopurine-refractory patients should be treated with anti-TNF or vedolizumab.[5]

In the present retrospective study, we aimed to assess relapse-free survival in patients with ASUC responding to IVS according to various maintenance therapy regimens. We therefore enrolled 142 consecutive patients followed in four academic Inflammatory Bowel Disease (IBD) centres.

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