Outcomes of Outpatient Advanced Therapy Exposed Patients Hospitalized With Severe Ulcerative Colitis

Natural History of Severe Ulcerative Colitis in a Community-Based Health Plan

Inflammatory Bowel Disease Clinical

Incidence of Colectomy During Long-term Follow-up After Cyclosporine-Induced Remission of Severe Ulcerative Colitis

Does the Cyclosporine Still Have a Potential Role in the Treatment of Acute Severe Steroid-Refractory Ulcerative Colitis?

Pushing the Pedal to the Metal: Should We Accelerate Infliximab Therapy for Patients With Severe Ulcerative Colitis?

AGA Clinical Practice Guidelines on the Management of Moderate to Severe Ulcerative Colitis

Background Up to 20% of patients with ulcerative colitis (UC) will require hospitalization for an acute severe flare. It is unclear whether outpatient exposure to biologics alters the outcomes of inpatient severe UC. We aimed to assess the outcomes of hospitalized severe UC patients exposed to biologics in the outpatient setting. Methods This was a multicenter, retrospective study of adult patients hospitalized with severe UC at University of Cambridge, Cambridge, St. Mark’s Hospital, London and Yale University, Connecticut (from 1/1/2012-11/1/2021). We included adult patients (age ≥ 18 years) who were hospitalized for a severe UC flare as determined by the treating clinician. The primary outcome was need for colectomy among outpatient biologic exposed vs biologic naïve patients. Secondary outcomes stratified by outpatient biologic exposure included length of hospitalization and need for rescue medical therapy. Results A total of 382 patients (53.2% male) with a median age of 35 years [interquartile range (IQR) 25-53] were reviewed. Outpatient biologic exposure was noted in 23.2% (n=86, 52 exposed to infliximab) while 76.8% (n=284) were naïve to biologics. Median disease duration was longer in the biologic exposed group at 6 years (IQR 2-11) compared to 2 years (IQR 1-8) in the biologic naïve group (p < 0.001). Biologic exposed group was more likely to have pancolitis (70.2% vs. 54.7%; p=0.04). The C-reactive protein (CRP) to albumin ratio was higher in the biologic naïve group was higher at 12.8 (IQR: 3.2-35) vs. 8 (IQR: 1-21.5) (p=0.004). The biologic exposed group was more likely to undergo colectomy at 25% (n=21) vs. 9.3% (n=26) in the biologic naïve group (p<0.001). The median hospital length of stay was 6 days (IQR: 4-9) in both groups (p=0.96). Need for rescue medical therapy 37.7% (n=107) in the biologic naïve group vs. 41.9% (n=36) in the biologic exposed group (p=0.49). Colectomy was associated with outpatient biologic exposure (44.7% vs. 19.9%, p=0.0002), Mayo UC endoscopic sub-score of 3 (81.6% vs. 55.1%, p=0.002), higher median CRP [70.6 (IQR:26.8-126.3) vs. 38.8 mg/dL (IQR: 9.7-94.7), p=0.04], lower median albumin [3 (IQR: 2.7-3.6) vs. 3.5 (IQR: 3-4) g/dL, p=0.0002], and female sex (61.2% vs. 44.8%, p=0.03). On multivariable analysis, only low albumin was independently associated with risk of colectomy (odds ratio: 3.31, 95% confidence interval 1.59-6.87, p=0.0005) Conclusion In our multicenter cohort, outpatient biologic exposure was associated with increased risk of colectomy among hospitalized patients with severe UC but on multivariable analysis only low albumin was independently associated with risk of colectomy. Further study of larger cohorts is warranted.

Infliximab for Ulcerative Colitis: Finally Some Answers

Severity of Primary Sclerosing Cholangitis and Ulcerative Colitis: Does Liver Transplantation Protect Against Colectomy?

Introduction: Infliximab (IFX) has been efficacious in reducing colectomy rates among patients with moderate-to severe ulcerative colitis, but predictors of colectomy within 30 days of IFX among patients with acute severe ulcerative colitis (ASUC) are less established. Methods: We performed a single-center retrospective analysis of patients who received at least one dose of IFX while admitted between 2011-2022. We assessed demographic, clinical and laboratory predictors of colectomy within 30 days of first IFX dose. Multivariable and time-to-event analysis using Kaplan-Meier with log-rank statistics were used to assess risk factors for colectomy within 30 days. Results: A majority of the 172 patients hospitalized with ASUC who received IFX received 10 mg/kg (87.79%). Overall, 22/172 patients (12.79%) underwent colectomy within 30 days of first IFX dose. On univariable analysis, age, sex, race, ethnicity, BMI and smoking status were not associated with risk of colectomy. Higher initial CRP was significantly associated with 30-day risk of colectomy (106.17 vs. 65.10 mg/dL among patients who did not undergo colectomy; p< 0.01), as was a decrease of CRP ≤50% prior to discharge (p< 0.01). Lower initial albumin [< 3 (36.36%), 3.0-3.5 (40.91%), >3.5 g/dL (22.73%)] was associated with our primary outcome (p=0.046), as was a higher number of bowel movements in a 24-hour period prior to discharge (5.6 vs. 3.9 among patients who did not undergo colectomy; p=0.0256). On multivariable analysis, higher initial CRP (aOR 1.01, 95% CI 1.00 – 1.02), ≤50% change in CRP after first dose of IFX (aOR 9.00, 95% CI 2.43 – 33.29) and higher number of bowel movements in a 24-hour period prior to discharge (aOR 1.24, 95% CI 1.01– 1.52) remained significantly associated with risk of colectomy when adjusting for relevant covariables (Table). On Kaplan-Meier analysis, initial CRP >100 mg/dL, albumin < 3 g/dL and change in CRP ≤50% prior to discharge were significantly associated with decreased time to colectomy (Figure). Conclusion: Among patients with ASUC, higher CRP, decrease of CRP ≤50% and higher number of bowel movements prior to discharge were associated with increased risk of colectomy within 30-days of receiving IFX. Initial CRP >100 mg/dL, albumin < 3 g/dL and decrease of ≤50% in CRP prior to discharge were associated with decreased time to colectomy. These results can identify patients at highest risk and impact clinical decision-making regarding need for and timing of colectomy in patients with ASUC receiving IFX.Figure 1.: Kaplan–Meier curve showing estimates of proportion of patients requiring colectomy within 30 days of first infliximab dose (A) comparing patients with albumin on admission < 3 g/dL and albumin on admission ≥ 3 g/dL (p=0.0488) and (B) comparing patients with CRP on admission > 100 mg/dL and CRP on admission ≤ 100 mg/dL (p<0.01). Table 1. - Multivariable Analysis Examining Predictors of Colectomy within 30 Days Among Patients Hospitalized with Acute Severe Ulcerative Colitis Receiving Infliximab. *p=0.015; **p<0.01; ***p=0.036 Variable adjOdds Ratio (95% Confidence Interval) Disease Duration (years) 0.95 (0.86 – 1.04) Family history of IBD No Reference Yes 0.53 (0.10 – 2.79) Extent of disease on admission Proctitis/Left sided colitis Reference Not documented 0.13 (0.01 – 2.04) Pancolitis 1.30 (0.35 – 4.85) GI infection No Reference Yes 2.13 (0.51 – 8.91) CRP on admission (mg/dL)* 1.01 (1.00 – 1.02) Serum albumin on admission >3.5 g/dL Reference 3-3.5 g/dL 1.83 (0.47 – 7.12) < 3 g/dL 3.77 (0.79 – 18.07) Percent change in CRP after first infliximab dose** >50% decrease Reference ≤50% decrease 9.00 (2.43 – 33.29) Number of bowel movements in 24-hour period prior to discharge*** 1.24 (1.01– 1.52)

Improved outcome of acute severe ulcerative colitis while using early predictors of corticosteroid failure and rescue therapies

Background Admission rates for patients with ulcerative colitis (UC) are decreasing, however patients admitted with a UC flare are at increased risk of colectomy. In recent years, numerous advanced therapies have emerged to treat flares and maintain remission. Many patients are now “bio-experienced”, defined as prior/current exposure to at least one advanced therapy. In flare management, colectomy is reserved for patients with severe or refractory disease, or to manage complications such as toxic megacolon or perforation. It is not known if a patient’s bio-exposure status (i.e. bio-experienced or bio-naive) affects their risk of requiring a colectomy when they are hospitalized for a UC flare. Such information is important to clinicians when choosing to initiate therapy, determining the timing of therapy escalation and allowing patients to understand their risk to make informed treatment decisions. Aims To assess the relative risk of 90-day colectomy in bio-experienced versus bio-naïve patients admitted to hospital with UC flare as well as secondary outcomes such as time to first advanced therapy in hospital and length of stay (LOS). Methods This is a single centre retrospective cohort study that included patients admitted with a diagnosis of UC flare to a major tertiary hospital in Edmonton, AB from Nov 2019 to Apr 2024. The cohort was designated as bio-naïve, having never received advanced therapies or bio-experienced, having received at least one advanced therapy prior to admission. Administrative data extraction and chart review was used to obtain the primary and secondary outcomes. Relative risk of colectomy was calculated between groups and a 95% confidence interval generated for this. The secondary outcomes were analyzed using an unpaired t-test with the significance level of p&amp;lt;0.05. For LOS with colectomy, given significant variance, median and IQR were reported instead. Results In total, there were 216 admissions; 87 patients were bio-experienced and 129 were bio-naïve at the time of admission. Twenty-six patients underwent colectomy within 90 days. Of the patients who were bio-experienced, 18.39% underwent colectomy compared to 7.75% in the bio-naïve group. The relative risk of 90-day colectomy in the bio-experienced compared to bio-naïve patients was 2.37 (1.13-4.98 95% CI). Secondary outcomes showed similar average length of stay, however bio-experienced patients were placed on advanced therapy sooner and those requiring colectomy had shortened LOS, compared to bio-naïve patients (Figure 1). Chart review for other secondary outcomes (eg. prior therapies, disease duration) is underway. Conclusions In this retrospective cohort study, we demonstrated that the relative risk of colectomy for UC patients admitted with flare is 2.3 fold higher in bio-experienced compared to bio-naïve patients. Figure 1 Funding Agencies None

The Use of Intestinal Ultrasound in Ulcerative Colitis—More Than a Mucosal Disease?

Objective. Infliximab (IFX) is a well-established treatment for both acute, severe ulcerative colitis (UC) and chronic, refractory UC. However, data on the long-term clinical outcome and colectomy rates after IFX treatment in a routine clinical setting are sparse. The aim of this study was to provide further data on the long-term effect of IFX for acute, severe and chronic, refractory UC in unselected patients treated at a single center. Material and Methods. A retrospective analysis of all patients (n = 52) treated with IFX for UC before February 2009 was performed. The material comprised 19 patients (37%) with acute, severe UC and 33 patients (63%) with chronic, refractory UC. The primary outcome was colectomy rate; the secondary outcome clinical response. Results. The overall colectomy rate was 27% (14/52 patients) after a median follow-up of 22 months (range 4–57 months). The colectomy rate was 37% (7/19 patients) in the group with acute, severe UC and 21% (7/33 patients) among those with chronic, refractory UC. In all, 77% of the patients had clinical response to IFX treatment with no difference between the two subgroups. Among those with an initial clinical response, 50% (20/40 patients) had sustained clinical response. Conclusion. IFX is of long-term benefit as rescue treatment in selected patients with acute, severe UC with about two-thirds of the patients avoiding colectomy. The beneficial effect on colectomy rate in chronic, refractory UC seems less convincing although these patients may still achieve a sustained clinical response.

Low Colectomy Rates in Ulcerative Colitis in an Unselected European Cohort Followed for 10 Years