Corticosteroid exposure prior to admission and predicting need for rescue therapy in acute severe ulcerative colitis

Evaluation of Acute Severe Ulcerative Colitis Predictors for Steroid Therapy Refractoriness

BACKGROUND

One-third of patients presenting with acute severe ulcerative colitis (ASUC) are steroid-refractory and require either colectomy or rescue therapy. Timely identification of risk factors predictive of steroid non-response in ASUC patients is crucial for initiating early rescue therapy.

AIM

To identify factors predicting steroid failure or colectomy in ASUC.

METHODS

Records of ASUC admissions over a six-year period in a tertiary inflammatory bowel disease center were included. Clinical variables, laboratory markers, and endoscopic scores at admission were obtained. The primary outcome was non-response to intravenous (IV) steroids. Univariate and multivariate regression analyses were performed to identify factors associated with steroid non-response. Day-one and day-three composite indices were calculated. Their predictive value was assessed against the outcomes of steroid failure and requiring colectomy.

RESULTS

One hundred and three ASUC patients were included, of which 51 were steroid non-responders. Among non-responders, 48 received rescue therapy, and 6 underwent colectomy at index admission (3 after rescue therapy and 3 without). Day-one albumin (OR 0.906, P = 0.043) and being on oral steroids at entry (OR 3.009, P = 0.014) predicted non-response to steroids in both univariate and multivariate analyses. Admission hemoglobin level predicted steroid non-response only in univariate (OR 0.982, P = 0.047). Although an old score, Travis criteria predicted both steroid non-response (OR 8.4, P = 0.001) and requiring colectomy (OR 22.19, P = 0.006).

CONCLUSION

Lower albumin levels and being on oral steroids at admission for ASUC can predict IV steroid failure, and we suggest the possibility of early initiation of advanced therapy in this subgroup.

Clinical Trial Design Considerations for Hospitalised Patients With Ulcerative Colitis Flares and Application to Study Hyperbaric Oxygen Therapy in the NIDDK HBOT-UC Consortium

BACKGROUND

Patients with ulcerative colitis (UC) who are hospitalised for acute severe flares represent a high-risk orphan population.

AIM

To provide guidance for clinical trial design methodology in these patients.

METHODS

We created a multi-centre consortium to design and conduct a clinical trial for a novel therapeutic intervention (hyperbaric oxygen therapy) in patients with UC hospitalised for moderate-severe flares. During planning, we identified and addressed specific gaps for inclusion/exclusion criteria; disease activity measures; pragmatic trial design considerations within care pathways for hospitalised patients; standardisation of care delivery; primary and secondary outcomes; and sample size and statistical analysis approaches.

RESULTS

The Truelove-Witt criteria should not be used in isolation. Endoscopy is critical for defining eligible populations. Patient-reported outcomes should include rectal bleeding and stool frequency, with secondary measurement of urgency and nocturnal bowel movements. Trial design needs to be tailored to care pathways, with early intervention focused on replacing and/or optimising responsiveness to steroids and later interventions focused on testing novel rescue agents or strategies. The PRECIS-2 framework offers a means of tailoring to local populations. We provide standardisation of baseline testing, venous thromboprophylaxis, steroid dosing, discharge criteria and post-discharge follow-up to avoid confounding by usual care variability. Statistical considerations are provided given the small clinical trial nature of this population.

CONCLUSION

We provide an outline for framework decisions made for the hyperbaric oxygen trial in patients hospitalised for UC flares. Future research should focus on the remaining gaps identified.

Predictors for colectomy in patients with acute severe ulcerative colitis: a systematic review and meta-analysis

OBJECTIVES

Acute severe ulcerative colitis (ASUC) poses challenges to patient management owing to its high surgical rate. This study aimed to identify predictors of colectomy in patients with ASUC.

DESIGN

This is a systematic review and meta-analysis.

DATA SOURCES

PubMed and Web of Science were searched up to April 2024.

ELIGIBILITY CRITERIA

Studies on the predictors of colectomy in adult patients with ASUC were eligible.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted the data using a prespecified data collection sheet. A qualitative synthesis was performed in tabular form. Random-effect meta-analyses were conducted using OR and 95% CI.

RESULTS

Forty-two studies were included in the systematic review. The reported variables can be categorised into biomarkers, auxiliary examination findings, demographic and clinical characteristics, and drug factors. Through meta-analysis, albumin (OR 0.39 (95% CI 0.26 to 0.59) per 1 g/dL increment, I2=0.0%), high C reactive protein level (2.63 (1.53 to 4.52), I2=29.6%), high erythrocyte sedimentation rate level (2.92 (1.39 to 6.14), I2=0.0%), low haemoglobin level (2.08 (1.07 to 4.07), I2=56.4%), fulfilling the Oxford criteria (4.42 (2.85 to 6.84), I2=0.0%), extensive colitis (1.85 (1.24 to 2.78), I2=47.5%), previous steroids (1.75 (1.23 to 2.50), I2=17.7%) or azathioprine (2.25 (1.28 to 3.96), I2=0.0%) use, and sarcopenia (1.90 (1.04 to 3.45), I2=0.0%) were identified as valuable predictors for colectomy within 1 year. The ulcerative colitis endoscopic index of severity (OR 2.41 (95% CI 1.72 to 3.39), I2=1.5%) was the only predictor found to predict colectomy over 1 year.

CONCLUSION

Identification of these predictors may facilitate risk stratification of patients with ASUC, drive personalised treatment and reduce the need for colectomy.

A personalised algorithm predicting the risk of intravenous corticosteroid failure in acute ulcerative colitis

BACKGROUND

An episode of acute ulcerative colitis (UC) represents an important watershed moment in a patient's disease course.

AIMS

To derive a personalised algorithm for identifying patients at high risk of corticosteroid non-response from variables available at hospital presentation using a large prospectively collected acute UC patient database and machine learning-based techniques.

METHODS

We analysed data from 682 consecutive presentations of acute UC. We used an Akaike information criterion-based elastic net model to select variables based on the 419 earliest presentations of acute UC (1996-2017). We constructed two risk-scoring algorithms, with and without utilising additional endoscopic variables, using logistic regression models. We validated these risk scores on separate cohorts of 181 (2018-2022) and 82 (2015-2022) acute UC presentations.

RESULTS

The partial risk of rescue (ROR) score included the admission indices of oral corticosteroid treatment, bowel frequency ≥6/24 h, albumin, CRP ≥12 mg/mL and log10CRP. The full ROR score incorporates the same variables with the addition of the Mayo endoscopic subscore and disease extent. The AUCs in the main validation cohort were 0.76 (95% CI: 0.69-0.83) and 0.78 (95% CI: 0.71-0.85) for the partial and full ROR scores, respectively.

CONCLUSIONS

These pragmatic personalised risk scores (available at www.severecolitis.com) have comparably strong performance characteristics and usability enabling the identification of individuals at high risk of corticosteroid non-response before or after endoscopic assessment. The ROR scores have the potential to challenge conventional acute UC treatment paradigms by identifying patients who may benefit from early rescue therapy or participation in relevant clinical trials.

Management of acute severe ulcerative colitis-an update for generalist and specialist clinicians

BACKGROUND

Acute severe ulcerative colitis (ASUC) is a potentially life-threatening medical emergency that occurs in up to 25% of patients with ulcerative colitis. Although intravenous corticosteroids remain the cornerstone of therapy, 30-40% of patients will not respond and need timely consideration of rescue therapy with (currently) either infliximab or ciclosporin or indeed colectomy, underscoring the importance of multidisciplinary care to ensure favourable outcomes for patients. We discuss the current evidence and present an approach to the management of ASUC for general and specialist clinicians caring for patients with ASUC.

SOURCES OF DATA

The information in this review is derived from data published in peer- reviewed academic journals and registered clinical trials.

AREAS OF AGREEMENT

Management of acute severe colitis requires a multidisciplinary approach with early initiation with steroids and timely escalation of treatment to either medical rescue therapy or surgery.

AREAS OF CONTROVERSY

Balancing the risks of delayed surgery vs. optimizing medical therapy, including accelerated dosing schedules for biologics, remains ambiguous.

GROWING POINTS

The position on newer molecules like Janus Kinase inhibitors, such as tofacitinib, is a growing area with early real-world data showing promise for steroid refractory ASUC.

AREAS TIMELY FOR DEVELOPING RESEARCH

Developing predictive biomarkers and clinical risk scores for personalized rescue therapy selection is an evolving area of research.

Systematic review: Scores used to predict outcomes in acute severe ulcerative colitis

Predictive scores for ASUC outcomes according to time of application.

Inflammatory Bowel Disease Treatments and Predictive Biomarkers of Therapeutic Response

Inflammatory bowel disease (IBD) is a chronic immune-mediated inflammation of the gastrointestinal tract with a highly heterogeneous presentation. It has a relapsing and remitting clinical course that necessitates lifelong monitoring and treatment. Although the availability of a variety of effective therapeutic options including immunomodulators and biologics (such as TNF, CAM inhibitors) has led to a paradigm shift in the treatment outcomes and clinical management of IBD patients, some patients still either fail to respond or lose their responsiveness to therapy over time. Therefore, according to the recent Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE-II) recommendations, continuous disease monitoring from symptomatic relief to endoscopic healing along with short- and long-term therapeutic responses are critical for providing IBD patients with a tailored therapy algorithm. Moreover, considering the high unmet need for novel therapeutic approaches for IBD patients, various new modulators of cytokine signaling events (for example, JAK/TYK inhibitors), inhibitors of cytokines (for example IL-12/IL-23, IL-22, IL-36, and IL-6 inhibitors), anti-adhesion and migration strategies (for example, β7 integrin, sphingosine 1-phosphate receptors, and stem cells), as well as microbial-based therapeutics to decolonize the bed buds (for example, fecal microbiota transplantation and bacterial inhibitors) are currently being evaluated in different phases of controlled clinical trials. This review aims to offer a comprehensive overview of available treatment options and emerging therapeutic approaches for IBD patients. Furthermore, predictive biomarkers for monitoring the therapeutic response to different IBD therapies are also discussed.