Cytapheresis re-induces high-rate steroid-free remission in patients with steroid-dependent and steroid-refractory ulcerative colitis

Abstract

BACKGROUND It is a crucial issue for patients with refractory ulcerative colitis (UC), including steroid-dependent and steroid-refractory patients, to achieve and maintain steroid-free remission. However, clinical studies focused on the achievement of steroid-free remission in refractory UC patients are insufficient. Cytapheresis (CAP) is a non-pharmacological extracorporeal therapy that is effective for active UC with fewer adverse effects. This study comprised UC patients treated with CAP and suggested the efficacy of CAP for refractory UC patients. AIM To clarify the efficacy of CAP in achieving steroid-free remission in refractory UC patients. METHODS We retrospectively reviewed the collected data from 55 patients with refractory UC treated with CAP. We analyzed the following points: (1) Efficacy of the first course of CAP; (2) Efficacy of the second, third, and fourth courses of CAP in patients who experienced relapses during the observation period; (3) Efficacy of CAP in colonic mucosa; and (4) Long-term efficacy of CAP. Clinical efficacy was evaluated using Lichtiger’s clinical activity index or Sutherland index (disease activity index). Mucosal healing was evaluated using Mayo endoscopic subscore. The primary and secondary endpoints were the rate of achievement of steroid-free remission and the rate of sustained steroid-free remission, respectively. Statistical analysis was performed using the paired t-test and chi-squared test. RESULTS The rates of clinical remission, steroid-free remission, and poor effectiveness after CAP were 69.1%, 45.5%, and 30.9%, respectively. There were no significant differences in rate of steroid-free remission between patients with steroid-dependent and steroid-refractory UC. The mean disease activity index and Lichtiger’s clinical activity index scores were significantly decreased after CAP ( P < 0.0001). The rates of steroid-free remission after the second, third, and fourth courses of CAP in patients who achieved steroid-free remission after the first course of CAP were 83.3%, 83.3%, and 60%, respectively. Mucosal healing was observed in all patients who achieved steroid-free remission after the first course of CAP. The rates of sustained steroid-free remission were 68.0%, 60.0%, and 56.0% at 12, 24, and 36 mo after the CAP. Nine patients (36%) had maintained steroid-free remission throughout the observation period. CONCLUSION Our results suggest that CAP effectively induces and maintains steroid-free remission in refractory UC and re-induces steroid-free remission in patients achieving steroid-free remission after the first course of CAP.

Adsorptive cytapheresis in ulcerative colitis: A non‐pharmacological therapeutic approach revisited

“…Moreover, intensive, twice‐a‐week GMA, proved more effective than the standard once‐a‐week schedule, in inducing mucosal healing and long‐term maintenance of remission in the absence of steroids 17 . Reducing the interval between sessions worked again in case of relapse 18 . These data support the conclusion of a previous meta‐analysis reporting that GMA is superior to corticosteroids in inducing clinical remission (OR 2.23) 38 .…”

“…In some centers, a single‐needle, single‐catheter technique, involving the use of a pump equipped with a valve controlling the direction of blood flow has been used 16 . The procedure is usually performed on a weekly basis, but more aggressive, twice‐a‐week strategies have been proposed to foster efficacy 17,18 …”

Efficacy of cytapheresis in patients with ulcerative colitis showing insufficient or lost response to biologic therapy

“…Although the background of the patients in these studies were different, the remission rates in CAP therapy ranged from 40.3%-73% (mean ± SD: 56.25 ± 16.03%, median: 55.85%, interquartile range: 41.475%-71.425%) and the steroid-free remission rates in CAP therapy ranged from 36%-56.3% (mean ± SD: 47.25 ± 9.99%, median: 48.35%, interquartile range: 37.425%-55.975%) (Figure 1 ). Among these studies, four[ 37 , 42 , 58 , 59 ] compared the rates of clinical remission between the patients exposed to thiopurines or IM and the patients unexposed to them. In all four studies significant differences were not observed in the rates of remission between patients exposed to thiopurines or IM and control.…”

“…Regarding the rate of steroid-free remission, two studies[ 59 , 62 ] compared the rates of steroid-free remission between the patients concomitantly treated with thiopurines or IM and the patients treated without them. These studies showed that significant differences were not observed between the patients concomitantly treated with thiopurines or IM and patients treated without them.…”

“…LCAP exerts its anti-inflammatory effects by removing activated leukocytes or platelets from the peripheral blood through extracorporeal circulation[ 42 ]. It has been reported that CAP is an effective therapeutic strategy for active refractory UC with fewer adverse effects[ 52 - 59 ]. In addition, it is notable that there have been no reports showing LOR to CAP during the treatment.…”