Long‐term outcome of patients with acute severe ulcerative colitis responding to intravenous steroids

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 followup 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. | INTRODUC TI ONUlcerative 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. 6Since the 1970s, the effectiveness of this intensive medical therapy has not changed over time, with an overall response rate of 67%. 4

Letter: long‐term outcomes of patients with acute severe ulcerative colitis after intravenous steroid therapy

“…Moreover, mean hemoglobin value of the study population of Salameh et al was 11.3 ± 2.0 g/dL. 1 We found that haemoglobin levels lower than 11.8 g/dL predicted lack of response to IV steroids in ASUC. 2 Despite the advent of biologic therapies, ASUC requiring hospitalisation and IV steroids is still a risk factor for early and late colectomy.…”

“…14.5% of our patients had colectomy during the follow-up period of 4.4 years [1.1-10 years] 2 ; and 15% of complete responders were operated on over the following decade according to Bojic et al5 ).In our cohort, 89% of patients who underwent colectomy had been on immunosuppressant treatment, 2 while Salameh et al reported that 61.7% of relapsing patients received immunomodulators 1. This suggests that immunomodulatory treatment is not very effective for maintenance therapy after ASUC.…”

“…They found relatively high relapse rates, but low colectomy rates during followup, and concluded that early and complete response to IV steroids, besides anti-TNF use could be associated with lower relapse rates. 1 Their reported response rate to IV steroids was surprisingly low (40.9%). 1 In our previous study, 110 of 183 patients (60.1%) with ASUC responded to IV steroids.…”

“…1 Their reported response rate to IV steroids was surprisingly low (40.9%). 1 In our previous study, 110 of 183 patients (60.1%) with ASUC responded to IV steroids. 2 It seems unlikely that the effectiveness of IV steroids has changed over time according to the systematic review and meta-regression of Turner et al 3 Therefore, the lower response rate might be attributable to the study design and definitions, including only patients with ASUC using modified Truelove and Witts criteria.…”

Letter: long‐term outcomes of patients with acute severe ulcerative colitis after intravenous steroid therapy—authors' reply

“…We thank Fabián et al for their interest in our work and appreciate their positive comments 1 . We recently reported a high rate of relapse in patients with acute severe ulcerative colitis (ASUC) responding to intravenous steroids 2 . In this retrospective multicentre cohort study, the risk of relapse was lower in those treated with anti‐TNF maintenance therapy.…”