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Choy MC, Li Wai Suen CFD, Con D, Boyd K, Pena R, Burrell K, Rosella O, Proud D, Brouwer R, Gorelik A, Liew D, Connell WR, Wright EK, Taylor KM, Pudipeddi A, Sawers M, Christensen B, Ng W, Begun J, Radford-Smith G, Garg M, Martin N, van Langenberg DR, Ding NS, Beswick L, Leong RW, Sparrow MP, De Cruz P. Intensified versus standard dose infliximab induction therapy for steroid-refractory acute severe ulcerative colitis (PREDICT-UC): an open-label, multicentre, randomised controlled trial. Lancet Gastroenterol Hepatol 2024:S2468-1253(24)00200-0. [PMID: 39236736 DOI: 10.1016/s2468-1253(24)00200-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/18/2024] [Accepted: 06/18/2024] [Indexed: 09/07/2024]
Abstract
BACKGROUND The optimal dosing strategy for infliximab in steroid-refractory acute severe ulcerative colitis (ASUC) is unknown. We compared intensified and standard dose infliximab rescue strategies and explored maintenance therapies following infliximab induction in ASUC. METHODS In this open-label, multicentre, randomised controlled trial, patients aged 18 years or older from 13 Australian tertiary hospitals with intravenous steroid-refractory ASUC were randomly assigned (1:2) to receive a first dose of 10 mg/kg infliximab or 5 mg/kg infliximab (randomisation 1). Block randomisation was used and stratified by history of thiopurine exposure and study site, with allocation concealment maintained via computer-generated randomisation. Patients in the 10 mg/kg group (intensified induction strategy [IIS]) received a second dose at day 7 or earlier at the time of non-response; all patients in the 5 mg/kg group were re-randomised between day 3 and day 7 (1:1; randomisation 2) to a standard induction strategy (SIS) or accelerated induction strategy (AIS), resulting in three induction groups. Patients in the SIS group received 5 mg/kg infliximab at weeks 0, 2, and 6, with an extra 5 mg/kg dose between day 3 and day 7 if no response. Patients in the AIS group received 5 mg/kg infliximab at weeks 0, 1, and 3, with the week 1 dose increased to 10 mg/kg and given between day 3 and day 7 if no response. The primary outcome was clinical response by day 7 (reduction in Lichtiger score to <10 with a decrease of ≥3 points from baseline, improvement in rectal bleeding, and decreased stool frequency to ≤4 per day). Secondary endpoints assessed outcomes to day 7 and exploratory outcomes compared induction regimens until month 3. From month 3, maintenance therapy was selected based on treatment experience, with use of thiopurine monotherapy, combination infliximab and thiopurine, or infliximab monotherapy, with follow-up as a cohort study up to month 12. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, NCT02770040, and is completed. FINDINGS Between July 20, 2016, and Sept 24, 2021, 138 patients were randomly assigned (63 [46%] female and 75 [54%] male); 46 received a first dose of 10 mg/kg infliximab and 92 received 5 mg/kg infliximab. After randomisation 1, we observed no significant difference in the proportion of patients who had a clinical response by day 7 between the 10 mg/kg and 5 mg/kg groups (30 [65%] of 46 vs 56 [61%] of 92, p=0·62; risk ratio adjusted for thiopurine treatment history, 1·06 [95% CI 0·94-1·20], p=0·32). We found no significant differences in secondary endpoints including time to clinical response or change in Lichtiger score from baseline to day 7. Two patients who received 10 mg/kg infliximab underwent colectomy in the first 7 days compared with no patients in the 5 mg/kg group (p=0·21). Three serious adverse events occurred in three patients in both the 10 mg/kg group and 5 mg/kg group. After randomisation 2, the proportions of patients with clinical response at day 14 (34 [74%] of 46 in the IIS group, 35 [73%] of 48 in the AIS group, and 30 [68%] of 44 in the SIS group, p=0·81), clinical remission at month 3 (23 [50%], 25 [52%], 21 [48%], p=0·92), steroid-free remission at month 3 (19 [41%], 20 [42%], 18 [41%], p=1·0), endoscopic remission at month 3 (21 [46%], 22 [46%], 21 [48%], p=0·98), and colectomy at month 3 (three [7%] of 45, nine [19%] of 47, five [12%] of 43, p=0·20) were not significantly different between groups. Between day 8 and month 3, the proportion of patients with at least one infectious adverse event possibly related to infliximab was two (4%) of 46 in the IIS group, eight (17%) of 48 in the AIS group, and eight (18%) of 44 in the SIS group (p=0·082). No deaths occurred in the study. INTERPRETATION Infliximab is a safe and effective rescue therapy in ASUC. In steroid-refractory ASUC, a first dose of 10 mg/kg infliximab was not superior to 5 mg/kg infliximab in achieving clinical response by day 7. Intensified, accelerated, and standard induction regimens did not result in a significant difference in clinical response by day 14 or in remission or colectomy rates by month 3. FUNDING Australian National Health and Medical Research Council, Gastroenterology Society of Australia, Gandel Philanthropy, Australian Postgraduate Award, Janssen-Cilag.
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Affiliation(s)
- Matthew C Choy
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia; Department of Medicine (Austin Health), University of Melbourne, Melbourne, VIC, Australia
| | - Christopher F D Li Wai Suen
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia; Department of Medicine (Austin Health), University of Melbourne, Melbourne, VIC, Australia
| | - Danny Con
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia; Department of Medicine (Austin Health), University of Melbourne, Melbourne, VIC, Australia
| | - Kristy Boyd
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia
| | - Raquel Pena
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia
| | - Kathryn Burrell
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia
| | - Ourania Rosella
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia
| | - David Proud
- Department of Colorectal Surgery, Austin Health, Melbourne, VIC, Australia
| | - Richard Brouwer
- Department of Colorectal Surgery, Austin Health, Melbourne, VIC, Australia
| | - Alexandra Gorelik
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Danny Liew
- Department of Medicine, University of Adelaide, Adelaide, SA, Australia
| | - William R Connell
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Emily K Wright
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Kirstin M Taylor
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, VIC, Australia
| | - Aviv Pudipeddi
- Department of Gastroenterology Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Michelle Sawers
- Department of Gastroenterology, Barwon Health, Geelong, VIC, Australia
| | - Britt Christensen
- Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Watson Ng
- Department of Gastroenterology, Liverpool Hospital, Sydney, NSW, Australia
| | - Jakob Begun
- Department of Gastroenterology, Mater Hospital, Brisbane, QLD, Australia
| | - Graham Radford-Smith
- Department of Gastroenterology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Mayur Garg
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia; Department of Gastroenterology, Northern Health, Melbourne, VIC, Australia
| | - Neal Martin
- Department of Gastroenterology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | | | - Nik S Ding
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Lauren Beswick
- Department of Gastroenterology, Barwon Health, Geelong, VIC, Australia
| | - Rupert W Leong
- Department of Gastroenterology Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Miles P Sparrow
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, VIC, Australia
| | - Peter De Cruz
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia; Department of Medicine (Austin Health), University of Melbourne, Melbourne, VIC, Australia.
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Li Wai Suen CFD, Seah D, Choy MC, De Cruz P. Factors Associated With Response to Rescue Therapy in Acute Severe Ulcerative Colitis. Inflamm Bowel Dis 2024; 30:1389-1405. [PMID: 37725044 DOI: 10.1093/ibd/izad183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Acute severe ulcerative colitis (ASUC) is a medical emergency for which colectomy is required in patients who do not respond to rescue therapy. While previous studies have predominantly focused on predicting outcome to first-line corticosteroid therapy, there is a need to understand the factors associated with response to rescue therapies in order to improve clinical outcomes. We reviewed the evidence regarding factors associated with response to rescue therapy in adults with ASUC and identified future directions for research. METHODS A systematic search of the literature was conducted, and 2 reviewers independently assessed studies for inclusion. RESULTS Of 3509 records screened, 101 completed studies were eligible for inclusion. We identified 42 clinical, hematological, biochemical, endoscopic, or pharmacological factors associated with response to rescue therapy. Older age (≥50 years), thiopurine experience, and cytomegalovirus or Clostridioides difficile infection were associated with a higher risk of nonresponse to rescue therapy. Biochemical factors associated with poorer response included an elevated C-reactive protein (CRP) ≥30mg/L on admission, hypoalbuminemia and an elevated ratio of CRP to albumin. Severe endoscopic findings, including a Mayo endoscopic score of 3 or Ulcerative Colitis Endoscopic Index of Severity ≥5, portended poorer outcomes. The role of fecal calprotectin and therapeutic value of measuring infliximab drug levels in ASUC remain to be defined. CONCLUSIONS Response to rescue therapy can be predicted by several specific factors, which would aid clinical decision-making. Existing and emerging factors should be integrated within predictive and prognostic models to help improve clinical outcomes.
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Affiliation(s)
- Christopher F D Li Wai Suen
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia
- Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, VIC, Australia
| | - Dean Seah
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia
| | - Matthew C Choy
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia
- Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, VIC, Australia
| | - Peter De Cruz
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia
- Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, VIC, Australia
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Vuyyuru SK, Nardone OM, Jairath V. Predicting Outcome after Acute Severe Ulcerative Colitis: A Contemporary Review and Areas for Future Research. J Clin Med 2024; 13:4509. [PMID: 39124775 PMCID: PMC11312513 DOI: 10.3390/jcm13154509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Revised: 07/25/2024] [Accepted: 07/30/2024] [Indexed: 08/12/2024] Open
Abstract
Acute Severe Ulcerative Colitis (ASUC) is a severe form of ulcerative colitis relapse which requires hospitalization and intensive medical intervention to avoid colectomy. The timely recognition of patients at risk of corticosteroid failure and the early initiation of medical rescue therapy are paramount in the management of ASUC. The choice of medical rescue therapy is influenced by multiple factors, especially patient's prior treatment history. This decision should involve the patient and ideally a multidisciplinary team of healthcare professionals, including gastroenterologists, radiologists, surgeons and enterostomal therapists. Although several predictive models have been developed to predict corticosteroid failure in ASUC, there is no single validated tool that is universally utilized. At present, infliximab and cyclosporine are the only agents systematically evaluated and recommended for medical rescue therapy, with recent reports of off-label utilization of tofacitinib and upadacitinib in small case series. The available evidence regarding the efficacy and safety of these oral small molecules for ASUC is insufficient to provide definitive recommendations. Early decision-making to assess the response to medical rescue therapy is essential, and the decision to pursue surgery in the case of treatment failure should not be delayed.
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Affiliation(s)
- Sudheer Kumar Vuyyuru
- Departments of Medicine, Division of Gastroenterology, Schulich School of Medicine & Dentistry, Western University, London, ON N6A 5C1, Canada
| | - Olga Maria Nardone
- Gastroenterology, Department of Public Health, University Federico II of Naples, 80131 Naples, Italy
| | - Vipul Jairath
- Departments of Medicine, Division of Gastroenterology, Schulich School of Medicine & Dentistry, Western University, London, ON N6A 5C1, Canada
- Division of Epidemiology and Biostatistics, Western University, London, ON N6A 5C1, Canada
- Lawson Health Research Institute, London, ON N6A 3K7, Canada
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Vuyyuru SK, Jairath V. Unresolved challenges in acute severe ulcerative colitis. Indian J Gastroenterol 2024; 43:9-14. [PMID: 38189896 DOI: 10.1007/s12664-023-01503-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Affiliation(s)
| | - Vipul Jairath
- Departments of Medicine, Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada.
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AbdelMeguid AMA, Whitehead E, Sebastian S. Modern practical management of acute severe colitis. Indian J Gastroenterol 2024; 43:78-92. [PMID: 38407787 DOI: 10.1007/s12664-024-01522-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 12/28/2023] [Indexed: 02/27/2024]
Abstract
Acute severe ulcerative colitis (ASUC) is one of life-threatening complications that occur in one-fifth of ulcerative colitis (UC) patients with significant morbidity and an estimated mortality rate up to 1%. There are no validated clinical scoring systems for ASUC. Intravenous corticosteroids remain the cornerstone for the management of ASUC patients However, one-third of patients are steroid refractory and require colectomy in the pre-biologic era or salvage therapy in the post-biologic era. The currently available predictors of non-response to steroids and salvages therapy are sub-optimal. Furthermore, there is a need for the development of clear outcome measures for ASUC patients. Although infliximab and cyclosporin are both effective as salvage therapy, they still carry a rate of treatment failure. Hence, there is an unmet need to explore alternative therapeutic options before colectomy particularly in prior infliximab-exposed patients. This may include the introduction of small molecules with rapid onset of action as a salvage or sequential therapy and the use of slow-onset other biological therapy after "bridging" with cyclosporine. In this article, we explore the current best evidence-based practice and detail the gaps in knowledge in the management of ASUC.
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Affiliation(s)
| | - Emma Whitehead
- IBD Unit, Hull University Teaching Hospitals, Hull, HU3 2JZ, UK
| | - Shaji Sebastian
- IBD Unit, Hull University Teaching Hospitals, Hull, HU3 2JZ, UK.
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Chen J, Zhang Y, Guo Q, Ren T, Tang N, Chen H, Zhang H. Development and validation of a risk model to predict the progression of ulcerative colitis patients to acute severe disease within one year. Expert Rev Gastroenterol Hepatol 2023; 17:1341-1348. [PMID: 37935651 DOI: 10.1080/17474124.2023.2279737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 11/01/2023] [Indexed: 11/09/2023]
Abstract
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.
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Affiliation(s)
- Jie Chen
- Department of Gastroenterology, The Yangzhou School of clinical Medicine of Nanjing Medical University, Yangzhou, People's Republic of China
- Department of Gastroenterology, Northern Jiangsu People's Hospital, Yangzhou, People's Republic of China
| | - Yue Zhang
- Department of Gastroenterology, Northern Jiangsu People's Hospital, Yangzhou, People's Republic of China
| | - Qiong Guo
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China
| | - Tianqi Ren
- Department of Gastroenterology, Northern Jiangsu People's Hospital, Yangzhou, People's Republic of China
| | - Nana Tang
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China
| | - Han Chen
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China
| | - Hongjie Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China
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Abstract
PURPOSE OF REVIEW Nearly one-third of patients with inflammatory bowel disease (IBD) do not achieve remission despite our best therapies. When this happens, it is critical to understand the reason for treatment failure. Once nonresponse is confirmed, these patients should be referred to an IBD centre for multidisciplinary care. This review will discuss the remaining treatment options, including escalation of biologics to unlicensed doses, combination biologics, nonvalidated therapies and surgical options. It will additionally provide updates in the management of acute severe ulcerative colitis (ASUC). RECENT FINDINGS There is an increasing interest in combination biologics to treat refractory IBD, although data supporting its safety and effectiveness are limited. The use of hyperbaric oxygen, mesenchymal stem cell therapy and dietary interventions also show early promise in this area. Studies have additionally focused on personalized therapy to identify aggressive phenotypes and predict treatment response in these challenging patients. In ASUC, infliximab and cyclosporine remain mainstays of treatment, and tofacitinib shows promise as a salvage therapy. SUMMARY Refractory IBD is common, yet large knowledge gaps remain. Recent and ongoing studies have focused on medical, surgical and dietary approaches with mixed success. Larger prospective studies are desperately needed to address this complex issue.
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Positioning biologics and small molecules in the management of moderate to severe ulcerative colitis. Curr Opin Gastroenterol 2021; 37:344-350. [PMID: 33731642 DOI: 10.1097/mog.0000000000000738] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW This review addresses the selection of biologic and small molecule therapy for patients with moderate to severe ulcerative colitis (UC). With several new treatment options approved within the past few years, an update in positioning is timely and relevant. RECENT FINDINGS Updates on the safety and comparative efficacy of approved therapeutic agents for UC are presented. Newly approved therapies including tofacitinib and ustekinumab, as well as where to position these treatments are discussed. Data on the first-ever head-to-head trial of biologic therapy in UC are examined. This review provides an evidence-based overview of the optimal management strategies of patients in both the inpatient and outpatient settings. SUMMARY As we move closer towards the goal of personalized therapy for our patients with UC, we hope to better select appropriate and effective treatment options. Newly approved therapies provide us with additional options for management. Future advancements in predictive serologic, mucosal, genetic, and fecal markers can enable us to tailor therapy to an individual patient.
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Garate ALSDV, Rocha TB, Almeida LR, Quera R, Barros JR, Baima JP, Saad-Hossne R, Sassaki LY. Treatment of acute severe ulcerative colitis using accelerated infliximab regimen based on infliximab trough level: A case report. World J Clin Cases 2021; 9:3219-3226. [PMID: 33969111 PMCID: PMC8080733 DOI: 10.12998/wjcc.v9.i13.3219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 02/04/2021] [Accepted: 03/10/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute severe ulcerative colitis (ASUC) is a complication of ulcerative colitis associated with high levels of circulating tumor necrosis factor alpha, due to the intense inflammation and faster stool clearance of anti-tumor necrosis factor drugs. Dose-intensified infliximab treatment can be beneficial and is associated with lower rates of colectomy. The aim of the study was to present a case of a patient with ASUC and megacolon, treated with hydrocortisone and accelerated scheme of infliximab that was monitored by drug trough level.
CASE SUMMARY A 22-year-old female patient diagnosed with ulcerative colitis, presented with diarrhea, rectal bleeding, abdominal pain, vomiting, and distended abdomen. During investigation, a positive toxin for Clostridium difficile and colonic dilatation of 7 cm consistent with megacolon were observed. She was treated with oral vancomycin for pseudomembranous colitis and intravenous hydrocortisone for severe colitis, which led to the resolution of megacolon. Due to the persistent severe colitis symptoms, infliximab 5 mg/kg was prescribed, monitored by drug trough level (8.8 μg/mL) and fecal calprotectin of 921 μg/g (< 30 μg/g). Based on the low infliximab trough level after one week from the first infliximab dose, the patient received a second infusion at week 1, consistent with the accelerated regimen (infusions at weeks 0, 1, 2 and 6). We achieved a positive clinical and endoscopic response after 6 mo of therapy, without the need for a colectomy.
CONCLUSION Infliximab accelerated infusions can be beneficial in ASUC unresponsive to the treatment with intravenous corticosteroids. Longitudinal studies are necessary to define the best therapeutic drug monitoring and treatment regimen for these patients.
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Affiliation(s)
| | - Thiara Barcelos Rocha
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu 18618687, São Paulo, Brazil
| | - Luciana Rocha Almeida
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu 18618687, São Paulo, Brazil
| | - Rodrigo Quera
- Inflammatory Bowel Disease Program, Gastroenterology, Medicine Department, Clínica Universidad de los Andes, Santiago 7550000, Chile
| | - Jaqueline Ribeiro Barros
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu 18618687, São Paulo, Brazil
| | - Julio Pinheiro Baima
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu 18618687, São Paulo, Brazil
| | - Rogerio Saad-Hossne
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu 18618687, São Paulo, Brazil
| | - Ligia Yukie Sassaki
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu 18618687, São Paulo, Brazil
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Assessment, endoscopy, and treatment in patients with acute severe ulcerative colitis during the COVID-19 pandemic (PROTECT-ASUC): a multicentre, observational, case-control study. Lancet Gastroenterol Hepatol 2021; 6:271-281. [PMID: 33545083 PMCID: PMC7906670 DOI: 10.1016/s2468-1253(21)00016-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/23/2020] [Accepted: 12/23/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND There is a paucity of evidence to support safe and effective management of patients with acute severe ulcerative colitis during the COVID-19 pandemic. We sought to identify alterations to established conventional evidence-based management of acute severe ulcerative colitis during the early COVID-19 pandemic, the effect on outcomes, and any associations with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and severe COVID-19 outcomes. METHODS The PROTECT-ASUC study was a multicentre, observational, case-control study in 60 acute secondary care hospitals throughout the UK. We included adults (≥18 years) with either ulcerative colitis or inflammatory bowel disease unclassified, who presented with acute severe ulcerative colitis and fulfilled the Truelove and Witts criteria. Cases and controls were identified as either admitted or managed in emergency ambulatory care settings between March 1, 2020, and June 30, 2020 (COVID-19 pandemic period cohort), or between Jan 1, 2019, and June 30, 2019 (historical control cohort), respectively. The primary outcome was the proportion of patients with acute severe ulcerative colitis receiving rescue therapy (including primary induction) or colectomy. The study is registered with ClinicalTrials.gov, NCT04411784. FINDINGS We included 782 patients (398 in the pandemic period cohort and 384 in the historical control cohort) who met the Truelove and Witts criteria for acute severe ulcerative colitis. The proportion of patients receiving rescue therapy (including primary induction) or surgery was higher during the pandemic period than in the historical period (217 [55%] of 393 patients vs 159 [42%] of 380 patients; p=0·00024) and the time to rescue therapy was shorter in the pandemic cohort than in the historical cohort (p=0·0026). This difference was driven by a greater use of rescue and primary induction therapies with biologicals, ciclosporin, or tofacitinib in the COVID-19 pandemic period cohort than in the historical control period cohort (177 [46%] of 387 patients in the COVID-19 cohort vs 134 [36%] of 373 patients in the historical cohort; p=0·0064). During the pandemic, more patients received ambulatory (outpatient) intravenous steroids (51 [13%] of 385 patients vs 19 [5%] of 360 patients; p=0·00023). Fewer patients received thiopurines (29 [7%] of 398 patients vs 46 [12%] of 384; p=0·029) and 5-aminosalicylic acids (67 [17%] of 398 patients vs 98 [26%] of 384; p=0·0037) during the pandemic than in the historical control period. Colectomy rates were similar between the pandemic and historical control groups (64 [16%] of 389 vs 50 [13%] of 375; p=0·26); however, laparoscopic surgery was less frequently performed during the pandemic period (34 [53%] of 64] vs 38 [76%] of 50; p=0·018). Five (2%) of 253 patients tested positive for SARS-CoV-2 during hospital treatment. Two (2%) of 103 patients re-tested for SARS-CoV-2 during the 3-month follow-up were positive 5 days and 12 days, respectively, after discharge from index admission. Both recovered without serious outcomes. INTERPRETATION The COVID-19 pandemic altered practice patterns of gastroenterologists and colorectal surgeons in the management of acute severe ulcerative colitis but was associated with similar outcomes to a historical cohort. Despite continued use of high-dose corticosteroids and biologicals, the incidence of COVID-19 within 3 months was low and not associated with adverse COVID-19 outcomes. FUNDING None.
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Grant RK, Jones GR, Plevris N, Lynch RW, Jenkinson PW, Lees CW, Manship TA, Jagger FAM, Brindle WM, Shivakumar M, Satsangi J, Arnott IDR. 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. Inflamm Bowel Dis 2021; 27:451-457. [PMID: 32572468 DOI: 10.1093/ibd/izaa088] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Indexed: 12/13/2022]
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.
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Affiliation(s)
- Rebecca K Grant
- The Edinburgh IBD Unit, Western General Hospital, Edinburgh, UK
| | | | - Nikolas Plevris
- The Edinburgh IBD Unit, Western General Hospital, Edinburgh, UK
| | | | | | - Charlie W Lees
- The Edinburgh IBD Unit, Western General Hospital, Edinburgh, UK
| | | | | | | | | | - Jack Satsangi
- University of Edinburgh, Edinburgh, UK.,Translational Gastro-intestinal Unit, Nuffield Department of Medicine, John Radcliffe Hospital, Oxford, UK
| | - Ian D R Arnott
- The Edinburgh IBD Unit, Western General Hospital, Edinburgh, UK
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12
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Conley TE, Fiske J, Subramanian S. How to manage: acute severe colitis. Frontline Gastroenterol 2021; 13:64-72. [PMID: 34970430 PMCID: PMC8666866 DOI: 10.1136/flgastro-2020-101710] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/28/2021] [Accepted: 02/02/2021] [Indexed: 02/04/2023] Open
Abstract
Acute severe ulcerative colitis (ASUC) is a medical emergency which is associated with significant morbidity and a mortality rate of 1%. ASUC requires prompt recognition and treatment. Optimal management includes admission to a specialist gastrointestinal unit and joint management with colorectal surgeons. Patients need to be screened for concomitant infections and thromboprophylaxis should be administered to mitigate against the elevated risk of thromboembolism. Corticosteroids are still the preferred initial medical therapy but approximately 30%-40% of patients fail steroid therapy and require rescue medical therapy with either infliximab or cyclosporine. Emergency colectomy is required in a timely manner for patients who fail rescue medical therapy to minimise the risk of adverse post-operative outcomes. We discuss current and emerging evidence in the management of ASUC and outline management approaches for clinicians involved in managing ASUC.
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Affiliation(s)
- Thomas Edward Conley
- Gastroenterology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Joseph Fiske
- Gastroenterology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Sreedhar Subramanian
- Gastroenterology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
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13
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Li JR, Ling FM, Chen YD, Xu MY, Zhu LR. Treatment of acute severe ulcerative colitis. Shijie Huaren Xiaohua Zazhi 2021; 29:87-92. [DOI: 10.11569/wcjd.v29.i2.87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Acute severe ulcerative colitis (ASUC) is a potentially life-threatening medical emergency. Due to the increasing incidence of ulcerative colitis in recent years, ASUC has become increasingly common in clinical practice. Presently, corticosteroids remain the first choice, whose efficacy should be evaluated after 3 d. If unsatisfactory, it should be switched to infliximab or cyclosporine salvage treatment timely. Besides, colectomy may be an option when medical treatment is ineffective or serious complications occur. This review describes the current treatment regimens for ASUC, with an aim to help develop treatment plans and improve the prognosis and life quality of patients with ASUC .
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Affiliation(s)
- Jun-Rong Li
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Fang-Mei Ling
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Yi-Dong Chen
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Ming-Yang Xu
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Liang-Ru Zhu
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
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14
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Alkhatry M, Al-Rifai A, Annese V, Georgopoulos F, Jazzar AN, Khassouan AM, Koutoubi Z, Nathwani R, Taha MS, Limdi JK. First United Arab Emirates consensus on diagnosis and management of inflammatory bowel diseases: A 2020 Delphi consensus. World J Gastroenterol 2020; 26:6710-6769. [PMID: 33268959 PMCID: PMC7684461 DOI: 10.3748/wjg.v26.i43.6710] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/15/2020] [Accepted: 10/12/2020] [Indexed: 02/06/2023] Open
Abstract
Ulcerative colitis and Crohn's disease are the main entities of inflammatory bowel disease characterized by chronic remittent inflammation of the gastrointestinal tract. The incidence and prevalence are on the rise worldwide, and the heterogeneity between patients and within individuals over time is striking. The progressive advance in our understanding of the etiopathogenesis coupled with an unprecedented increase in therapeutic options have changed the management towards evidence-based interventions by clinicians with patients. This guideline was stimulated and supported by the Emirates Gastroenterology and Hepatology Society following a systematic review and a Delphi consensus process that provided evidence- and expert opinion-based recommendations. Comprehensive up-to-date guidance is provided regarding diagnosis, evaluation of disease severity, appropriate and timely use of different investigations, choice of appropriate therapy for induction and remission phase according to disease severity, and management of main complications.
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Affiliation(s)
- Maryam Alkhatry
- Gastroenterology and Endoscopy Department, Ibrahim Bin Hamad Obaid Allah Hospital, Ministry of Health and Prevention, Ras Al Khaiman, United Arab Emirates
| | - Ahmad Al-Rifai
- Department of Gastroenterology, Sheikh Shakbout Medical City, Abu Dhabi, United Arab Emirates
| | - Vito Annese
- Department of Gastroenterology, Valiant Clinic, Dubai, United Arab Emirates
- Department of Gastroenterology and Endoscopy, American Hospital, Dubai, United Arab Emirates
| | | | - Ahmad N Jazzar
- Gastroenterology Division, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Ahmed M Khassouan
- Digestive Disease Unit, Rashid Hospital, Dubai, United Arab Emirates
| | - Zaher Koutoubi
- Digestive Disease Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates
| | - Rahul Nathwani
- Department of Gastroenterology, Mediclinic City Hospital, Dubai, United Arab Emirates
- Department of Gastroenterology, Mohammed Bin Rashid University, Dubai, United Arab Emirates
| | - Mazen S Taha
- Gastroenterology and Hepatology, Tawam Hospital, Al Ain, United Arab Emirates
| | - Jimmy K Limdi
- Department of Gastroenterology, The Pennine Acute Hospitals NHS Trust, Manchester Academic Health Sciences, University of Manchester, Manchester M8 5RB, United Kingdom
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15
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Fiske J, Conley T, Sebastian S, Subramanian S. Infliximab in acute severe colitis: getting the right dose. Frontline Gastroenterol 2020; 11:427-429. [PMID: 33104078 PMCID: PMC7569519 DOI: 10.1136/flgastro-2020-101407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 03/02/2020] [Accepted: 03/19/2020] [Indexed: 02/04/2023] Open
Abstract
Acute severe colitis is a medical emergency and requires prompt treatment with intravenous steroids. Infliximab is typically used as rescue therapy in those who fail to respond to corticosteroids. This article outlines the altered pharmacokinetics of infliximab in acute severe UC and summarised the latest published data surrounding accelerated infliximab dosing.
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Affiliation(s)
- Joseph Fiske
- Department of Gastroenterology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Thomas Conley
- Department of Gastroenterology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Shaji Sebastian
- IBD Unit, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Sreedhar Subramanian
- Department of Gastroenterology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
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16
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Sebastian S, Myers S. Letter: infliximab induction regimens in steroid-refractory acute severe colitis-a propensity score analysis. Authors' reply. Aliment Pharmacol Ther 2020; 51:666-667. [PMID: 32100353 DOI: 10.1111/apt.15647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
| | - Sally Myers
- IBD Unit, Hull University Hospitals NHS Trust, Hull, UK
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17
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Li Wai Suen CFD, Choy MC, De Cruz P. Letter: infliximab induction regimens in steroid-refractory acute severe colitis-a propensity score analysis. Aliment Pharmacol Ther 2020; 51:665-666. [PMID: 32100345 DOI: 10.1111/apt.15630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Christopher F D Li Wai Suen
- Department of Gastroenterology, Austin Health, Melbourne, Vic., Australia.,Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, Vic, Australia
| | - Matthew C Choy
- Department of Gastroenterology, Austin Health, Melbourne, Vic., Australia.,Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, Vic, Australia
| | - Peter De Cruz
- Department of Gastroenterology, Austin Health, Melbourne, Vic., Australia.,Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, Vic, Australia
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18
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Rivière P, Laharie D, Marteau P. Concise Commentary: Second Line Is Not Second Best-Continuing Validity of the Oxford Criteria in the Management of Acute Severe Ulcerative Colitis. Dig Dis Sci 2020; 65:581-582. [PMID: 31489565 DOI: 10.1007/s10620-019-05788-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Pauline Rivière
- Department of Hepatogastroenterology and Digestive Oncology, Haut-Lévêque Hospital, CHU de Bordeaux, Bordeaux, France
| | - David Laharie
- Department of Hepatogastroenterology and Digestive Oncology, Haut-Lévêque Hospital, CHU de Bordeaux, Bordeaux, France
| | - Philippe Marteau
- Sorbonne Université - INSERM-ERL 1157, CHU Saint-Antoine 27 - UMR7203 - Saint Antoine IBD Network, APHP, Hôpital Saint Antoine, Paris, France. .,Hepatology and Gastroenterology, Hôpital Saint Antoine, 184 Faubourg St Antoine, 75012, Paris, France.
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19
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Sebastian S. Letter: should we intensify infliximab in acute severe ulcerative colitis? Author's reply. Aliment Pharmacol Ther 2020; 51:188. [PMID: 31850578 DOI: 10.1111/apt.15569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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20
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Sebastian S, Kennedy NA, Subramanian S, Raine T. Editorial: accelerated infliximab induction-it's time to settle the debate! Authors' reply. Aliment Pharmacol Ther 2019; 50:1061-1062. [PMID: 31625193 DOI: 10.1111/apt.15498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Shaji Sebastian
- IBD Unit, Department of Gastroenterology, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Nicholas A Kennedy
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | | | - Tim Raine
- Addenbrooke's Hospital, Cambridge, UK
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21
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Sebastian S, Myers S, Argyriou K, Martin G, Los L, Fiske J, Ranjan R, Cooper B, Goodoory V, Ching HL, Jayasooriya N, Brooks J, Dhar A, Shenoy AH, Limdi JK, Butterworth J, Allen PB, Samuel S, Moran GW, Shenderey R, Parkes G, Lobo A, Kennedy NA, Subramanian S, Raine T. Infliximab induction regimens in steroid-refractory acute severe colitis: a multicentre retrospective cohort study with propensity score analysis. Aliment Pharmacol Ther 2019; 50:675-683. [PMID: 31456297 DOI: 10.1111/apt.15456] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 06/23/2019] [Accepted: 07/19/2019] [Indexed: 12/12/2022]
Abstract
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.
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22
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Sebastian S, Lisle J, Subramanian S, Dhar A, Shenoy A, Limdi J, Butterworth J, Allen PB, Samuel S, Moran G, Shenderey R, Parkes G, Raine T, Lobo AJ, Kennedy NA. Practice pattern variability in the management of acute severe colitis: a UK provider survey. Frontline Gastroenterol 2019; 11:272-279. [PMID: 32587670 PMCID: PMC7307042 DOI: 10.1136/flgastro-2019-101277] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 07/22/2019] [Accepted: 07/31/2019] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Lack of comparative trial data on dosing regimens of infliximab in patients with acute severe ulcerative colitis (ASUC) failing intravenous corticosteroids has resulted in variability of rescue regimes in ASUC with potential impact on clinical outcomes. We aimed to evaluate practice variability and physician perspectives in decision-making with rescue therapy. METHODOLOGY An internet-based survey of members of the inflammatory bowel disease (IBD) section of the British Society of Gastroenterology was conducted. The survey evaluated provider characteristics and general practice in the setting of ASUC, followed by a vignette with linked questions. RESULTS The response rate of the survey was 31% (209/682 IBD section members). 134 (78%) reported they would use standard infliximab dose (5 mg/kg) while 37 (22%) favoured a higher front-loading dose of 10 mg/kg citing low albumin, high C-reactive protein as their reason for their preference. IBD specialists chose the higher front-loading dose more often compared with other gastroenterologists (p=0.01) In the specific case vignette, accelerated induction (AI) was favoured by 51% of the respondents while 25% used the standard induction regime and 19% favoured colectomy. IBD specialists more often favoured AI compared with other gastroenterologists (p=0.03) with the main reason being presence of predictors of low infliximab levels (74%). The reasons cited for favouring standard induction (n=57) included lack of evidence for AI (18), their usual practice (11), unlicensed regime (7), and safety concerns (4). CONCLUSIONS There are significant variations in practice in the use of infliximab rescue therapies with an urgent need for development of care pathways to standardise practice.
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Affiliation(s)
- Shaji Sebastian
- IBD Unit, Department of Gastroenterology, Hull University Teaching Hospitals NHS Trust, Hull, UK
- Hull York Medical School, Hull, UK
| | - Jessica Lisle
- Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Sreedhar Subramanian
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK
| | - Anjan Dhar
- Department of Gastroenterology, County Durham and Darlington NHS Foundation Trust, Bishop Auckland, UK
| | - Achut Shenoy
- Department of Gastroenterology, Colchester Hospital University NHS Foundation Trust, Colchester, UK
| | - Jimmy Limdi
- Department of Gastroenterology, The Pennine Acute Hospitals NHS Trust, Manchester, UK
| | - Jeffrey Butterworth
- Department of Gastroenterology, Royal Shrewsbury Hospitals NHS Trust, Shrewsbury, UK
| | - Patrick B Allen
- department of Gastroenterology, Ulster Hospital, Dundonald, UK
| | - Sunil Samuel
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Gordon Moran
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK
| | - Richard Shenderey
- Department of Gastroenterology, Airedale NHS Foundation Trust, Keighley, UK
| | - Gareth Parkes
- Department of Gastroenterology, Royal London Hospital, London, UK
| | - Tim Raine
- Department of Gastroenterology, Addenbrooke’s Hospital, Cambridge, UK
| | - Alan J Lobo
- Gastroenterology Unit, Royal Hallamshire Hospital, Sheffield, UK
| | - Nicholas A Kennedy
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
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