Acute severe ulcerative colitis: management advice for internal medicine and emergency physicians

Recent Advances in the Management of Acute Severe Ulcerative Colitis

Acute severe ulcerative colitis is a medical emergency requiring inpatient treatment with intravenous steroids. Approximately one-third of patients do not respond to steroids sufficiently and require medical rescue therapy. Infliximab and cyclosporine are equally effective rescue agents, though infliximab is often preferred by clinicians for ease of use and greater familiarity. The use of cyclosporine is becoming more frequent, however, in patients previously exposed to infliximab. Those patients not exhibiting an adequate response to rescue therapy require colectomy. There is increasing interest in modified medical treatment to rescue the need for surgery. Janus kinase inhibitors may provide benefits when used alongside steroids from admission or as a rescue agent, but further randomised trials are needed to clearly establish their role. Intensified dosing of infliximab when used as a rescue therapy has shown mixed results but seems sensible in patients with low albumin and high disease burden. In this review, we describe the current established treatment pathways and report newer developments and evolving concepts that may in the future improve the care of patients with acute severe ulcerative colitis.

Efficacy and safety of Xileisan combined with mesalazine for ulcerative colitis: A meta-analysis and trial sequential analysis

BACKGROUND

The benefits and risks of Xileisan (XLS) in the treatment of ulcerative colitis (UC) remain unclear.

AIM

The present study aimed to evaluate the efficacy and safety of the combination of XLS and mesalazine when treating UC.

METHODS

We searched eight databases for clinical trials evaluating the combination of XLS and mesalazine in the treatment of UC, up to January 2024. Meta-analysis and trial sequential analysis (TSA) were performed using Revman 5.3 and TSA 0.9.5.10 beta, respectively.

RESULTS

The present study included 13 clinical studies involving 990 patients, of which 501 patients received XLS combined with mesalazine while 489 patients received mesalazine alone. The meta-analysis showed that, in terms of efficacy, the combination of XLS and mesalazine significantly improved the clinical efficacy rate by 22% [risk ratio (RR) = 1.22; 95%CI: 1.15-1.28; P < 0.00001] and mucosal improvement rate by 25% (RR = 1.25; 95%CI: 1.12-1.39; P = 0.0001), while significantly reducing the duration of abdominal pain by 2.25 days [mean difference (MD) = -2.25; 95%CI: -3.35 to -1.14; P < 0.0001], diarrhea by 2.06 days (MD = -2.06; 95%CI: -3.92 to -0.20; P = 0.03), hematochezia by 2.32 days (MD = -2.32; 95%CI: -4.02 to -0.62; P = 0.008), tumor necrosis factor alpha by 16.25 ng/mL (MD = -16.25; 95%CI: -20.48 to -12.01; P < 0.00001), and interleukin-6 by 14.14 ng/mL (MD = -14.14; 95%CI: -24.89 to -3.39; P = 0.01). The TSA indicated conclusiveness in the meta-analysis of the efficacy endpoints. In terms of safety, the meta-analysis revealed that the combination of XLS and mesalazine did not increase the occurrence of total and gastrointestinal adverse events, abdominal distension, and erythema (P > 0.05). The TSA showed non conclusive findings in the meta-analysis of the safety endpoints. Harbord's test showed no publication bias (P = 0.734).

CONCLUSION

Treatment with XLS alleviated the clinical symptoms, intestinal mucosal injury, and inflammatory response in patients with UC, while demonstrating good safety.

Development and validation of a risk model to predict the progression of ulcerative colitis patients to acute severe disease within one year

BACKGROUND AND AIMS

Acute severe ulcerative colitis (ASUC) is strongly associated with poor prognosis. We aimed to establish and validate a model predicting ASUC occurrence within 1 year after ulcerative colitis(UC) diagnosis.

METHODS

A cohort of UC patients diagnosed between 2018 and 2020 at Northern Jiangsu People's Hospital, who were followed up for one year, was used to develop a risk prediction model. An independent cohort from January to December 2021, monitored until December 2022 at the at the First Affiliated Hospital of Nanjing Medical University, was used for external validation. A multivariable logistic regression analysis was conducted to investigate the adjusted association between six risk factors and ASUC. Subsequently, a simplified model was developed by eliminating a relatively insignificant risk factor to create an easy-to-use index.

RESULTS

The prediction model incorporates five parameters: disease extent, endoscopic appearance, histopathology, baseline response medication, and relapse frequency. It generates a nomogram in the end. The discriminant ability (c-index) was separately calculated as 0.982 and 0.925 in the development and validation cohorts.

CONCLUSIONS

The risk prediction model for developing ASUC within one year demonstrated excellent reliability and validity, which could be a straightforward and clinically valuable tool for predicting ASUC occurrence within 1 year.

CLINICAL TRIAL REGISTRATION

ChiCTR2300071794.

3D printed multi-drug-loaded suppositories for acute severe ulcerative colitis

Acute severe ulcerative colitis (ASUC) is a growing health burden that often requires treatment with multiple therapeutic agents. As inflammation is localised in the rectum and colon, local drug delivery using suppositories could improve therapeutic outcomes. Three-dimensional (3D) printing is a novel manufacturing tool that permits the combination of multiple drugs in personalised dosage forms, created based on each patient's disease condition. This study, for the first time, demonstrates the feasibility of producing 3D printed suppositories with two anti-inflammatory agents, budesonide and tofacitinib citrate, for the treatment of ASUC. As both drugs are poorly water-soluble, the suppositories' ability to self-emulsify was exploited to improve their performance. The suppositories were fabricated via semi-solid extrusion (SSE) 3D printing and contained tofacitinib citrate and budesonide in varying doses (10 or 5 mg; 4 or 2 mg, respectively). The suppositories displayed similar dissolution and disintegration behaviours irrespective of their drug content, demonstrating the flexibility of the technology. Overall, this study demonstrates the feasibility of using SSE 3D printing to create multi-drug suppositories for the treatment of ASUC, with the possibility of titrating the drug doses based on the disease progression.

Evidence-based pathogenesis and treatment of ulcerative colitis: A causal role for colonic epithelial hydrogen peroxide

In this comprehensive evidence-based analysis of ulcerative colitis (UC), a causal role is identified for colonic epithelial hydrogen peroxide (H₂O₂) in both the pathogenesis and relapse of this debilitating inflammatory bowel disease. Studies have shown that H₂O₂ production is significantly increased in the non-inflamed colonic epithelium of individuals with UC. H₂O₂ is a powerful neutrophilic chemotactic agent that can diffuse through colonic epithelial cell membranes creating an interstitial chemotactic molecular “trail” that attracts adjacent intravascular neutrophils into the colonic epithelium leading to mucosal inflammation and UC. A novel therapy aimed at removing the inappropriate H₂O₂ mediated chemotactic signal has been highly effective in achieving complete histologic resolution of colitis in patients experiencing refractory disease with at least one (biopsy-proven) histologic remission lasting 14 years to date. The evidence implies that therapeutic intervention to prevent the re-establishment of a pathologic H₂O₂ mediated chemotactic signaling gradient will indefinitely preclude neutrophilic migration into the colonic epithelium constituting a functional cure for this disease. Cumulative data indicate that individuals with UC have normal immune systems and current treatment guidelines calling for the suppression of the immune response based on the belief that UC is caused by an underlying immune dysfunction are not supported by the evidence and may cause serious adverse effects. It is the aim of this paper to present experimental and clinical evidence that identifies H₂O₂ produced by the colonic epithelium as the causal agent in the pathogenesis of UC. A detailed explanation of a novel therapeutic intervention to normalize colonic H₂O₂, its rationale, components, and formulation is also provided.