Steroid Use May Increase Relapse Risk in Some Patients With Ulcerative Colitis

Jim Kling

May 27, 2022

Patients who have histologically active ulcerative colitis (UC) with a Mayo endoscopic subscore (MES) of 1 and a history of steroid use may be at increased risk for clinical relapse, according to a new single-center, retrospective analysis.

In recent years, treat-to-target approaches in UC have incorporated clinician and patient-reported outcomes, along with endoscopic remission, defined as MES 1 or less. However, additional studies showed a higher risk of relapse with MES 1, and the STRIDE-II (Selecting Therapeutic Targets in Inflammatory Bowel Disease) guidelines released in 2021 suggest that only MES 0 indicates endoscopic healing.

Nevertheless, there is concern that striving to achieve MES 0 could lead to overtreatment, since MES values are somewhat subjective, and patients with MES 1 sometimes report few or no symptoms. This led to the current study by Gyeol Seong, MD, and colleagues, published in Inflammatory Bowel Diseases.

Dr Miguel Regueiro

Commenting on the study, Miguel Regueiro, MD, chair for the Digestive Disease and Surgery Institute and a professor of medicine at the Cleveland Clinic said "the question has always been, if the patient is in endoscopic remission and clinically feels well, how important is it to have histologically normal mucosa?"

In their retrospective study, Seong and colleagues analyzed data from 492 patients. The median age was 48, and 51.6% were male. The median duration of disease was 78 months. During a median follow-up of 549 days, 18.7% experienced a relapse, defined as "change or escalation of medication, hospitalization due to the aggravation of UC, or total colectomy." Of these patients, 39.4% had used steroids and 51.4% had a MES score of 0 at the index endoscopy, and 70.5% had histologic improvement, as defined by a Geboes score of less than 3.1.

A Geboes score of 3.1 or higher and a history of steroid use was associated with an increased cumulative incidence of clinical relapse, compared with a Geboes score lower than 3.1 and no steroid use (P = .001). In a multivariate analysis, histologic activity alone was not a predictor of relapse. Among patients with an MES score of 1, a history of steroid use predicted risk of relapse (adjusted hazard ratio, 2.102; P = .006).

Although Regueiro said the new findings would not change his current practice, he does incorporate histopathology in clinical decision-making. In cases where a patient is in endoscopic remission but has histologic activity, he will consider adjusting the current medication rather than changing to a different therapeutic. "I wouldn't recommend that we switch patients off one therapy to another just because of histologic activity."

That's because patients often improve dramatically after effective therapy. Regueiro said: "The one concern is whether the next medicine works as well as what the patient is already on? I'm also worried that we burn through our biologics too quickly. We go from one to another and another, sometimes I think we just need to optimize the one they're on."

The study does have the potential to influence surveillance for dysplasia, according to Regueiro, noting that a recent retrospective analysis showed an increased risk of dysplasia in UC with persistent histologic activity. "This suggests the need for a colonoscopy in a patient who has had ulcerative colitis for a number of years, even if there's improvement but, on biopsy, there's evidence of inflammation."

According to Regueiro, such patients might benefit from a fecal calprotectin measurement in 3-6 months to monitor for colonic inflammation. Increased levels might be a sign that the patient is skipping medication doses, although other factors, like respiratory infections, can also explain the results. If the patient's medication adherence is good, another therapy can be added or the dose increased, and the next endoscopy can be pushed up.

A key limitation to the study by Seong and colleagues is that it was based in South Korea. "Would this be the same in different countries and different populations? That is still a question," said Regueiro.

Regueiro has received unrestricted educational grants from Abbvie, Janssen, UCB, Pfizer, Takeda, Celgene, Genentech, Gilead, Bristol-Myers Squibb, and Lilly. He has been on advisory boards or consulted for numerous companies. He also has relationships with the following CME companies: CME Outfitters, Imedex, GI Health Foundation, Cornerstones, Remedy, MJH Life Sciences, Medscape, MDEducation, WebMD, and HMPGlobal.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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