Extracorporeal photopheresis (ECP) is a leukapheresis-based immunomodulating procedure reported beneficial in some immune disorders, such as graft vs. host disease or multiple systemic sclerosis.1, 2 A few years ago, Reinisch et al. published preliminary results of a prospective pilot study suggesting that ECP could represent a safe corticosteroid-sparing approach in patients with steroid-dependent Crohn's disease (CD).3 More recently, an open-label, multicentre, prospective trial confirmed the steroid-sparing potential of ECP in CD.4 In addition, an open-label trial has investigated the safety and clinical effect of ECP in patients with moderate-to-severe active CD refractory or intolerant to antitumour necrosis factor (TNF) agents or immunosuppressants.5 The results of this uncontrolled pilot study suggested that ECP was well tolerated and clinical remission and response were achieved at 12 weeks in 25% and 50% respectively. Given that most of the medical therapies effective in CD are also beneficial in ulcerative colitis (UC), ECP theoretically represents a promising therapeutic approach. Up to now, ECP safety, tolerability, acceptance and efficacy have not been reported in UC. Here, we report the preliminary results from a prospective clinical pilot study that we conducted to investigate the safety and potential efficacy of ECP in refractory chronic active UC patients, who represent a particularly difficult-to-treat population, often requiring colectomy. Seven consecutive out-patients with moderate-to-severe active UC refractory to standard medications, including anti-TNF agents, were prospectively treated with ECP during a 12-week period (induction with twice weekly procedures from week 1 to 4 followed by a maintenance regimen with two procedures every other week from week 5 to 12). The schedule of ECP therapy adopted in this study was derived from the experience of ECP in CD.5 A total of 112 procedures were performed during the study. None was delayed or suppressed, and patient acceptance was good. Neither serious side effects, nor acute exacerbations of the disease were recorded within the study period. Minor side effects including superficial venous thrombophlebitis in one patient, and mild and transitory headaches were observed. Laboratory parameters were unremarkable. Overall, five of seven patients achieved clinical response after 4 weeks of ECP induction therapy. However, all but one experienced relapse during the maintenance phase. Only one patient among responders achieved a sustained clinical remission associated with mucosal healing during the 12-week period of therapy. In addition, ECP failed to permit corticosteroid sparing or discontinuation. Median serum CRP levels and the Mayo endoscopic subscore did not significantly differ between baseline and the end of ECP therapy. The tolerability, acceptability and safety of ECP in UC are in accordance with previous findings in other chronic diseases.1-5 Overall, ECP is minimally invasive, well tolerated and easily performed by an experienced staff in only 2 h per session. However, the repetitive and time-consuming sessions of ECP, as well as its relatively low availability, except in academic centres, may represent substantial limitations for its use in clinical practice in IBD. In addition, its relatively long delay of action and whether ECP represents a modifier of the disease course remain to be elucidated. We acknowledge that our preliminary data in UC should be interpreted with caution, given the very small number of patients studied in a nonrandomised, open-label design. However, in contrast to CD, our uncontrolled pilot data suggest that ECP does not exert clinical benefit in patients with moderate-to-severe active UC refractory to other available therapies. Declaration of personal and funding interests: None.
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May 1, 2024
Xiao Xian Qian 
Open Access