The ACE (Albumin, CRP and Endoscopy) Index in Acute Colitis: A Simple Clinical Index on Admission that Predicts Outcome in Patients With Acute Ulcerative Colitis

Abstract

Background Intravenous (IV) steroids remain the first-line treatment for patients with acute ulcerative colitis (UC). However, 30% of patients do not respond to steroids, requiring second-line therapy and/or surgery. There are no existing indices that allow physicians to predict steroid nonresponse at admission. We aimed to determine if admission biochemical and endoscopic values could predict response to IV steroids. Methods All admissions for acute UC (ICD-10 K51) between November 1, 2011, and October 31, 2016 were identified. Case note review confirmed diagnosis; clinical, endoscopic, and laboratory data were collected. Steroid response was defined as discharge home with no further therapy for active UC. Nonresponse was defined as requirement for second-line therapy or surgery. Univariate and binary logistic regression analyses were employed to identify factors associated with steroid nonresponse. Results Two hundred and thirty-five acute UC admissions were identified, comprising both acute severe and acute nonsevere UC; 155 of the 235 patients (66.0%) responded to steroids. Admission C-reactive protein (CRP) (P = 0.009, odds ratio [OR] 1.006), albumin (P < 0.001, OR 0.894) and endoscopic severity (P < 0.001, OR 3.166) differed significantly between responders and nonresponders. A simple UC severity score (area under the curve [AUC] 0.754, P < 0.001) was derived from these variables; 78.1% (25 of 32) of patients with concurrent CRP ≥50 mg/L, albumin ≤30 g/L, and increased endoscopic severity (severe on physician’s global assessment) (maximum score = 3) did not respond to IV steroids (positive predictive value [PPV] 78.1%, negative predictive value [NPV] 87.1%). Conclusions More than three quarters of patients scoring 3 (albumin ≤30 g/L, CRP ≥50 mg/L, and increased endoscopic severity) did not respond to IV steroids. This combination of parameters (ACE) identifies on admission a high-risk population who may benefit from earlier second-line medical treatment or surgical intervention.

Optimal Management of Acute Severe Ulcerative Colitis (ASUC): Challenges and Solutions

“… 10 Combining low albumin levels (<30 g/L) with elevated an CRP (>50 mg/L) and a severe score on endoscopic evaluation (the so-called ACE-index) predicted failure to corticosteroids in 78% of cases in a large retrospective study including 235 ASUC patients. 12 Faecal calprotectin levels >1922 µg/g were found to have a 97% specificity for colectomy in a Scottish prospective study including 90 ASUC patients, but this was accompanied by low sensitivity (24%) limiting its clinical application. 13 In another retrospective Chinese cohort of 71 ASUC patients, faecal calprotectin levels >1672 µg/g on day 3 after colonoscopy predicted colectomy with a sensitivity of 80.2% and a specificity of 66.7%.…”

Point-of-Care Testing and Home Testing: Pragmatic Considerations for Widespread Incorporation of Stool Tests, Serum Tests, and Intestinal Ultrasound

“…Further, scoring systems that combine biomarkers with clinical information such as patient-reported outcomes (PROs) and clinical activity may have additional efficacy. For example, for patients at admission for acute severe UC, a maximum ACE index 80 (albumin 30 g/L þ CRP 50 mg/L þ endoscopic Mayo score ¼3) predicted nonresponse to intravenous corticosteroids with a positive predictive value of 78% and a negative predictive value of 87%. Combining high CRP, high FC, and low hemoglobin at therapy discontinuation is associated with an increased risk of relapse.…”

Optimising Early Management of Acute Severe Ulcerative Colitis in the Biologics Era: Admission Model for Intensification of Therapy in Acute Severe Colitis (ADMIT–ASC)

“…[9][10][11][12][13][14] Nevertheless, consistent data suggest that in the region of 40% of patients with ASC fail to respond to intravenous corticosteroids. [9,10,14]. Predictive models to guide the introduction of medical rescue therapy based on early response to corticosteroids, typically by day three, are in widespread use.…”

“…[4] The subsequent success of ciclosporin or infliximab as rescue therapy in a proportion of patients with no response to corticosteroids [5][6][7][8] led to protocol-driven algorithms of management that have reduced mortality and colectomy rates. [9][10][11][12][13][14] Nevertheless, consistent data suggest that in the region of 40% of patients with ASC fail to respond to intravenous corticosteroids. [9,10,14].…”