Infliximab induction regimens in steroid‐refractory acute severe colitis: a multicentre retrospective cohort study with propensity score analysis

Abstract

Summary Background Accelerated induction regimens of infliximab have been proposed to improve response rates in patients with steroid‐refractory acute severe colitis. Aim To determine the differences in outcome for acute severe ulcerative colitis between accelerated and standard‐dose infliximab Methods We collected data on hospitalised patients receiving differing regimens of rescue therapy for steroid‐refractory acute severe ulcerative colitis. Our primary outcome was 30‐day colectomy rate. Secondary outcomes were colectomy within index admission, and at 90 days and 12 months. We used propensity score analysis with optimal calliper matching using high risk covariates defined a priori to reduce potential provider selection bias. Results We included 131 patients receiving infliximab rescue therapy; 102 received standard induction and 29 received accelerated induction. In the unmatched cohort, there was no difference by type of induction in the 30‐day colectomy rates (18% vs 20%, P = .45), colectomy during index admission (13% vs 20%, P = .26) or overall colectomy (20% vs 24%, P = .38). In the propensity score‐matched cohort of 52 patients, 30‐day colectomy (57% vs 27%, P = .048) and index admission colectomy (53% vs 23%, P = .045) rates were higher in those receiving standard induction compared to accelerated induction but there was no difference in overall colectomy rates (57% vs 31%, P = .09). There was no significant difference in length of stay or in complication and infection rates. Conclusion In a propensity score‐matched cohort, steroid‐refractory acute severe ulcerative colitis patients, short‐term, but not long‐term, colectomy rates appear to be lower in those receiving an accelerated induction regimen.

Editorial: accelerated infliximab induction—it's time to settle the debate! Authors' reply

“…Chedid and Kane for their thoughtful editorial 1 on our paper evaluating the impact of accelerated induction in corticosteroid-refractory acute severe colitis. 2 We agree that, in the absence of results from an adequately powered RCT, propensity score matching analysis of cohort studies is useful to identify clinical benefits when therapeutic decisions are very heterogenous. We also agree that almost all of the cohort studies so far have not reported data to support the use of accelerated induction dosing regimens despite compelling pharmacokinetic and pharmacodynamic data.…”

Letter: should we intensify infliximab in acute severe ulcerative colitis? Author's reply

“…Laharie and Riviere for their thoughtful comments on the use of infliximab rescue therapy and accelerated induction in the setting of steroid-refractory acute severe colitis as reported in our recent paper. 1,2 I fully appreciate their own observation 3 that the 1-year colectomy rates have not declined based on randomised controlled trial evidence.…”

Letter: should we intensify infliximab in acute severe ulcerative colitis?

“…The multicentre retrospective study conducted by Sebastian et al , provides additional information on this pending question. It showed that patients treated with intensified doses had higher initial C‐reactive protein (CRP) levels and lower albumin levels but similar colectomy rates at 1 year than patients receiving the standard induction regimen . Their results illustrate that physicians have already integrated biomarkers into their daily management of patients admitted for ASUC.…”