Abstract
Background: Effectiveness of corticosteroids in immunosuppressed patients with inflammatory bowel disease (IBD) has not been completely elucidated.Aims: To assess the effectiveness and examine the long-term follow-up of systemic or low-bioavailability oral steroid treatment for moderate flare-ups in patients treated with immunosuppressive drugs.Methods: Immunosuppressed patients with inflammatory bowel disease (IBD) from our population-data registry were analyzed. For statistical analysis, the chi-square test, Mann-Whitney U test, and Kaplan-Meier survival analysis were used as appropriate.Results: A total of 392 patients with IBD and a median of 82 (range, 6–271) months of immunosuppressive (IMM) treatment were identified. The mean follow-up was 87 months (range, 6–239 months). A total of 89 patients (23%) needed at least one steroid course during their follow-up. Average time from IMM to steroid treatment was 26 (range, 6–207) months. In patients with CD, fibrostenotic (B2) and fistulizing (B3) behaviors [p = 0.005; odds ratio (OR): 2.284] were risk factors for using steroids after IMM treatment. In patients with UC, no statistically significant variables were identified. Of the 89 patients who received one first steroid course, 49 (55%) stepped up to biological treatment or surgery after a median of 13 months (range, 0–178), 19 (21%) were treated with repeated steroid courses, and 31 (35%) required no further treatment. Patients with CD had a higher risk (p = 0.007; OR: 3.529) of receiving biological treatment or surgery than patients with UC. The longer the patients with UC (more months) spent using steroids, the greater the risk of requiring treatment with biological drugs or surgery (p = 0.009).Conclusion: A total of 23% of the immunosuppressed patients with IBD received at least one course of steroid treatment. In patients under immunosuppression treated with at least a course of steroids, CD patients were more likely stepped up to biologics and/or surgery than UC patients. In patients with CD, B2/B3 behavior pattern were significant risk factors. After one course of steroids only 35% of immunosuppressed IBD patients remained in remission without needing treatment scalation.
Highlights
In 1955, Truelove and Witts [1] were the first to demonstrate the efficacy of corticosteroids to induce remission in patients with inflammatory bowel disease (IBD): moderate to severe ulcerative colitis (UC) patients treated with hydrocortisone (100 mg/day) did have a clearly better response than those receiving placebo, with statistically significant differences in hard endpoints as mortality
A total of 4 patients (1%) with Crohn’s disease (CD) required treatment with a biological drug prior to starting their IMM treatment, and this was associated with the need for taking corticosteroids during evolution (p = 0.038)
Reinforcing the results of other published cohorts [13], the results of our study show that the fibrostenotic and fistulizing patterns in CD are statistically significant factors associated with the need for corticosteroid treatment in immunosuppressed patients; likely because this reflects a greater severity in the clinical evolution of this behavior pattern and has been reflected in follow-up, epidemiological-incident cohort studies [14]
Summary
In 1955, Truelove and Witts [1] were the first to demonstrate the efficacy of corticosteroids to induce remission in patients with inflammatory bowel disease (IBD): moderate to severe ulcerative colitis (UC) patients treated with hydrocortisone (100 mg/day) did have a clearly better response than those receiving placebo, with statistically significant differences in hard endpoints as mortality. Until now corticosteroids continue to be the most widely used drugs for the treatment of moderate and severe flare-ups in both Crohn’s disease (CD) and UC [2, 3]. The main effects of systemic corticosteroids (prednisone or equivalent) are to induce remission of moderate and severe outbreaks in patients with CD [evidence level (EL) 1] [4] and UC (EL 1) [5], with high quality of evidence (QL) and strong recommendation [6]. For low-bioavailability systemic corticosteroids, 9 mg of oral budesonide is the treatment of choice to induce remission in patients with ileal CD, both in mild (EL 2) and moderate (EL 1) flares [4]. Effectiveness of corticosteroids in immunosuppressed patients with inflammatory bowel disease (IBD) has not been completely elucidated
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