Rapid induction of mucosal healing by intensive granulocyte and monocyte adsorptive aphaeresis in active ulcerative colitis patients without concomitant corticosteroid therapy

Abstract

Sirs, We read with great interest the review article by Thanaraj, et al. concerning granulocyte/monocyte adsorptive aphaeresis (GMAA) for ulcerative colitis (UC).1 Despite the promising effect of intensive GMAA (twice/week) on active UC patients2, the effect of intensive GMAA in active UC patients without concomitant corticosteroid therapy remains unclear. Recently, we evaluated the effect of ten sessions of intensive, compared with once weekly, GMAA on clinical and endoscopic remission in active UC patients who did not receive corticosteroid therapy, but continued other medications. Active UC patients [clinical activity index (CAI) score ≥7 points] without concomitant corticosteroid therapy were enrolled. Primary efficacy of the treatment was evaluated by the ratio of clinical remission (CAI ≤ 4) at 2, 4, 6, 8 and 10 weeks (Figure 1A). Secondary efficacy was evaluated by the proportion of patients with mucosal healing at 1 week after completion of intensive or weekly GMAA. Mucosal healing was defined using the absolute endoscopic index (EI) of the Mayo score of 0 or 1.3 The protocol and patients’ informed consent forms were reviewed and approved by the institutional Review Board of Saiseikai Nakatzu Hospital. (A) The protocols for the intensive and weekly granulocyte/monocyte adsorptive aphaeresis (GMAA) regimens. (B) The proportion of patients in clinical remission: intensive GMAA induced significantly more rapid clinical remission than weekly GMAA at 2, 4 and 6 weeks after starting GMAA treatment. *P < 0.001. (C) (a) Mucosal healing: the endoscopic index of the Mayo score in the intensive GMAA group was significantly lower than that in the weekly GMAA group at 1 week after the completion of GMAA. (b) Mucosal healing at 1 week after the completion of GMAA treatment occurred in significantly more patients in the intensive GMAA group than in the weekly GMAA group. *P < 0.001. (D) The proportions of patients who did not relapse after cessation of GMAA: intensive GMAA, bold lines; weekly GMAA, dotted lines. Kaplan–Meier analysis revealed that the cumulative nonrelapsing curve was significantly different between intensive and weekly GMAA groups (Breslow–Gehan–Wilcoxon test, P = 0.041). Of the 99 patients with active UC who underwent GMAA without corticosteroid administration, 35 patients received intensive GMAA, and 64 patients were treated with weekly GMAA. There were no significant differences in clinical parameters (age, gender, duration of disease, extent of disease, CAI score and EI of Mayo score) between the two groups. All patients in both groups completed ten sessions of GMAA. Intensive GMAA induced significantly more rapid clinical remission than weekly GMAA at 2, 4 and 6 weeks (Figure 1B). The proportion of patients achieving mucosal healing by intensive GMAA was significantly higher than that of patients achieving mucosal healing by weekly GMAA (Figure 1C). Cumulative nonrelapse ratio in the patients treated with intensive GMAA was significantly higher than that in weekly GMAA (Figure 1D). No serious side effects were observed during this study. In conclusion, these results suggest that twice weekly GMAA therapy might be considered as a first-line therapy for patients with active UC prior to corticosteroid treatment, although further controlled studies with a larger number of patients are necessary. Declaration of personal and funding interests: None.