Acute severe ulcerative colitis in children: A systematic review

Abstract

Pediatric ulcerative colitis (UC) has a more severe phenotype, reflected by more extensive disease and a higher rate of acute severe exacerbations. The pooled steroid-failure rate among 291 children from five studies is 34% (95% confidence interval [CI]: 27%-41%). It is suggested that corticosteroids should be dosed between 1-1.5 mg/kg up to 40-60 mg daily. Food restriction has a limited role in severe UC and should be generally discouraged in children who do not have a surgical abdomen. Appraisal of radiologic findings in children must recognize the variation in colonic width with age and size. Data suggest that the Pediatric UC Activity Index (PUCAI), determined at day 3, should be used to screen for patients likely to fail corticosteroids (>45 points), and at day 5 to dictate the introduction of second-line therapy (>65-70 points). Cyclosporine is successful in children with severe colitis but its use should be restricted to 3-4 months while bridging to thiopurine treatment (pooled short-term success rate 81% [95% CI: 76%-86%]; n = 94 from eight studies). Infliximab may be as effective as cyclosporine (75% pooled short-term response (95% CI: 67%-83%); n = 126, six studies) with a pooled 1-year response of 64% (95% CI: 56%-72%). In toxic megacolon, in patients refractory to one salvage medical therapy, and in chronic severe disease, colectomy may be preferred. Decision-making regarding colectomy in children must consider the toxicity of medication consumed over many future years, the quality of life and self-image associated with either choice, as well as both functional outcomes and, in females, fertility following pouch procedures.

Inflammatory Bowel Disease in Childhood and Adolescence

“…Acute severe ulcerative colitis in children and adolescents is treated with methylprednisolone (1 to 1.5 mg/ kg/day intravenously in 2 divided doses, maximum 60 mg/day) (13,33). Until thiopurines take effect, second-line treatment involves calcineurin inhibitors (cyclosporine, tacrolimus) or infliximab.…”

Management of Acute Severe Colitis in Children With Ulcerative Colitis in the Biologics Era

“…36 Pediatric cyclosporine data come from 8 retrospective case series (total of 94 children) in which the rate and adverse events were similar to those reported in adults. 7,37 The pooled short-term response was 81%, but only 39% avoided colectomy in the long-term. 7 Heterogeneity in the definition of disease activity, concomitant therapies, follow-up period (1-5 years), dose, and route of administration (half started with oral therapy) limit interpretation of these combined studies.…”

“…7,37 The pooled short-term response was 81%, but only 39% avoided colectomy in the long-term. 7 Heterogeneity in the definition of disease activity, concomitant therapies, follow-up period (1-5 years), dose, and route of administration (half started with oral therapy) limit interpretation of these combined studies. The better long-term success rates were, in part, related to the introduction of azathioprine.…”

“…6,27 To date, 4 small retrospective studies (44 patients in total) and 1 large prospective study of 128 children have reported the short-term response rate to CS therapy in pediatric severe colitis. 6,7 Similar to adults, in prospective studies, IV CS are also considered first-line therapy for ASC in the pediatric population. 28 Despite the predominance of extensive disease in children with UC, data concerning severe pediatric UC are sparse.…”

“…Short-term and 1-year colectomy rates have declined since the use of infliximab in children with ASC to 9% on discharge and 19% by 1 year. 7 Initial infliximab dosage is 5 mg/kg over 2 to 4 hours; subsequent doses are given 2 and 6 weeks after the initial infusion. Some centers use higher doses (10 mg/kg) or infuse the second dose after 7 to 10 days (maintenance therapy can be given every 8 weeks after induction, if clinically indicated).…”