Introduction

Acute severe ulcerative colitis (ASUC) represents a life-threatening medical emergency¹. Patients with ASUC require hospitalization and instant medical treatment, with corticosteroids remaining the primary initial therapy. One-third of ASUC patients are steroid non-responders². Management of ASUC patients should be based on efficient and fast assessment due to the need for further treatment decisions.

Aims & Methods

Our study aimed to create a new ASUC algorithm to predict corticosteroid response on the first day of hospital admission. A new Inflammatory Duration Index (IDI) was created by multiplying the onset duration of symptoms of UC prior to hospital admission and CRP to Albumin Ratio^2,3. A cross-sectional study included 103 newly diagnosed patients with UC hospitalized at the University Clinical Center of Serbia from 2020 to 2023. Patients included in the study fulfilled the criteria for ASUC according to Truelove's and Witts' severity index (62 male and 41 female, age ranging from 18 to 75 years). Descriptive statistics, Spearman's correlation, logistic regression, and ROC analysis were used to assess the predictive value of the score.

Results

The Inflammatory Duration Index (IDI) showed a significant negative correlation with glucocorticoid response (Spearman’s rho = -0.383, p < 0.01). Logistic regression analysis revealed the score's predictive capacity for treatment outcomes. The ROC curve analysis showed an area under the curve (AUC) of 0.722, suggesting a good diagnostic ability to predict the glucocorticoid response. If we were to determine a sensitivity of 91%, this ratio would have to value less than 120 to predict the complete response to glucocorticoids.

Conclusion

References

1. Truelove SC, Witts LJ. Cortisone in ulcerative colitis; final report on a therapeutic trial. Br Med J. 1955;2:1041-1048.
   
2. Nakase H. Acute Severe Ulcerative Colitis: Optimal Strategies for Drug Therapy. Gut Liver. 2023;17(1):49-57.
   
3. Gibson DJ, Hartery K, Doherty J, et al. CRP/Albumin Ratio: An Early Predictor of Steroid Responsiveness in Acute Severe Ulcerative Colitis. J Clin Gastroenterol. 2018;52(6):e48-e52.
4. Reinisch W, Wang Y, Oddens BJ, Link R. C-reactive protein, an indicator for maintained response or remission to infliximab in patients with Crohn’s disease: a post-hoc analysis from ACCENT I. Aliment Pharmacol Ther. 2012;35(5):568–76.

Introduction

Acute Severe Colitis (ASC) is a medical and surgical emergency that requires prompt and well-coordinated treatment. The initial treatment typically involves intravenous corticosteroids. However, a significant number of patients (around 30-40%) do not respond to corticosteroids and need alternative treatment. Predicting resistance to the first-line treatment early on is a challenge that has not been fully addressed. A new index called ADMIT-ASC (Admission Model for Intensification of Therapy in ASC), which considers biological and endoscopic data, has been developed to predict the failure of steroid treatment.
Our goal is to validate this index's effectiveness in predicting corticosteroid resistance in ASC associated with ulcerative colitis (ASUC).

Aims & Methods

We conducted a retrospective chart review of 210 patients admitted to the gastroenterology department at Sahloul Sousse for ASUC between March 2010 and February 2020. Failure of corticosteroid therapy was defined as the need for second-line medical treatment or colectomy.
The ADMIT-ASC score is an index ranging from 0 to 4, calculated by adding points based on specific parameters at admission: CRP ≥ 100 mg/L (1 point), albumin ≤ 25 g/L (1 point), and endoscopic UCEIS score ≥ 4 (1 point) or ≥ 7 (2 points). The area under the ROC curve (AUROC) was calculated to evaluate the accuracy of this score in predicting the failure of corticosteroid therapy.

Results

Two hundred and seventy patients were included in the study, with an average age of 33.5 years and a male-to-female ratio of 0.68. Of these patients, 62.8% had a history of UC, while ASC was the initial episode in 37.2% of cases. Fifty-two point thirty-eight percent (52.38%) of patients did not respond to intravenous corticosteroid treatment. Among them, 34.3% responded to ciclosporin, 2.4% to infliximab, and 5.2% underwent salvage colectomy. The average ADMIT-ASC score was 2.14 ± 0.99. Patients with scores of 0, 1, 2, 3, and 4 had response rates of 100%, 62.7%, 56%, 43.4%, and 25%, respectively (p=0.01). The failure rate of first-line medical treatment was 52.7% for a score ≥ 2 and 62% for a score ≥ 3 (95% CI). The AUROC of ADMIT-ASC in predicting corticosteroid resistance was 0.628 (p=0.01, 95% CI [0.552; 0.703]).

Conclusion

The ADMIT-ASC index seems to be a reliable predictor of response to corticosteroid therapy in ASC patients, starting from admission. This could help identify patients early on who would benefit from switching to second-line treatment promptly. However, larger prospective studies are needed to confirm these results.

Disclosure

I confirm that I do not have any conflicts of interest regarding this subject

Introduction

Rescue treatment is administered to patients with acute severe ulcerative colitis (ASUC) who do not respond sufficiently to the initial treatment with intravenous (iv) corticosteroids. Gastrointestinal ultrasound (GIUS) can be used to detect the degree of inflammation in ulcerative colitis and show response in the treatment of ASUC^1,2, but can it be used to detect treatment response of rescue treatment?

Aims & Methods

Can GIUS be used for early prediction of treatment response in patients receiving rescue treatment for ulcerative colitis?
Patients with ulcerative colitis were included from June 2020 to Nov 2024 at two hospitals in Bergen, Norway and treated with iv corticosteroids. At day 3 to 5 patients with insufficient clinical response were treated with infliximab (10mg/kg) as rescue. The patients were examined with GIUS before rescue treatment (baseline), at the day of the 2nd infusion (after 1-2 weeks) and after 3 months. Bowel wall thickness (BWT), bowel wall vessel density with colour Doppler, loss of haustration and fatty tissue reaction was registered for every segment of the colon as well as an activity score (UC-score) based on these parameters³. The two main outcomes of the study based on the partial MAYO score (pMAYO) at 3 months. Clinical response was defined as a change in pMAYO ≥ 3 points and ≥ 30% and with an absolute reduction in the rectal bleeding score ≥ 1 or with the score for rectal bleeding ≤ 1. Clinical remission was defined as pMAYO ≤2.

Results

68 patients with colitis were recruited and of these 37 failed the initial treatment with iv corticosteroids and were given rescue treatment. At baseline 8 had left-sided colitis while 29 had subtotal or total colitis. After 3 months 3 patients had received surgery, 28/34 had treatment response compared to baseline and 24/34 were in remission. There were significantly more patients with left-sided colitis in remission (p=0.034). At the 2^nd infusion there were no significant differences between responders and non-responders for the GIUS parameters, but patients in remission at 3 months had significantly lower BWT in the ascending colon (1.3 ±0.5 vs 2.9 ±2.2 mm, p=0.002) and the transverse colon (1.7 ±0.9 vs 2.8 ±0.9 mm, p<0.001), lower sum of BWT (9.1 ±3.0 vs 13.1 ±5.0 mm, p=0.005) and UC-score (8.0 ±4.7 vs 12.9 ±7.2, p=0.018). At 3 months there was a significant difference in BWT for all segments, the sum of BWT (7.0 ±2.6 vs 14.0 ±4.5, p<0.001) and the UC-score (3.9 ±4.6 vs 16.3 ±5.6, p<0.001) for responders. For patients in remission similar results were found except for the rectum. The sum of BWT (6.8 ±2.6 vs 11.9 ±4.6 mm, p<0.001) as well as the UC-score (3.8 ±4.6 vs 11.7 ±7.8, p<0.001) was significantly lower.

Conclusion

The significant differences in BWT of the ascending and transverse colon at the 2^nd infusion could reflect prognostic differences between left-sided and total colitis. At 3 months the BWT of all colon segments was lower except for the rectum for patients in remission.

References

1) Ilvemark J, Wilkens R, Thielsen P, et al. Early Intestinal Ultrasound Predicts Intravenous Corticosteroid Response in Hospitalised Patients With Severe Ulcerative Colitis. J Crohns Colitis. Nov 23 2022;16(11):1725-1734. doi:10.1093/ecco-jcc/jjac083
2) Nylund, K., et al. ⟪ Sonorescue⟫-treatment response in acute severe Ulcerative Colitis measured with ultrasound. In: J Crohns Colitis. Great Clarendon St, Oxford OX2 6DP, England: Oxford Univ press, 2025. p. i239-i239.
3) Bots S, Nylund K, Lowenberg M, Gecse K, D'Haens G. Intestinal Ultrasound to Assess Disease Activity in Ulcerative Colitis: Development of a novel UC-Ultrasound Index. J Crohns Colitis. Aug 2 2021;15(8):1264-1271. doi:10.1093/ecco-jcc/jjab002

Disclosure

Odd Helge Gilja has received speaker’s honoraria from AbbVie, Bracco, Allmirall, GE healthcare, Takeda AS, Ferring AS, Allergan and Janssen-Cilag and has served as a consultant for Bracco, GE Healthcare, Takeda and Samsung. ​The other authors have nothing to dislose.

Introduction

Acute severe ulcerative colitis (ASUC) is a potentially life-threatening emergency that requires timely management. Intravenous corticosteroids are the first line therapy, but around 30% of patients fail to respond. Rescue therapy is effective in reducing short-term colectomy rates but its impact on disease course in the medium/long-term is not well characterized.

Aims & Methods

We aimed to assess if non-response to corticoids (and subsequent need for rescue therapy) in patients admitted with a first episode of ASUC is associated with worse disease-related outcomes in the long-term.
We conducted a retrospective study of all patients admitted with ASUC in the Gastroenterology department of a Portuguese tertiary center between 2018-2024. ASUC diagnosis was established according to Truelove and Witts’ criteria. Response to intravenous corticoids was defined as discharge without need for rescue therapy and/or colectomy. Patients with a previous admission for ASUC before the study period were excluded.
Patient files were reviewed and demographic, clinical, laboratory and endoscopic data was collected regarding the admission for ASUC and subsequent follow-up. Considered disease-related outcomes were need for switch of maintenance therapy, need for readmission and need for colectomy. Subanalyses were performed according to response to corticoid therapy. Statistical analysis was done using Stata version 12.1.

Results

A total of 35 patients hospitalized with a first episode of ASUC were included, 51.4% (n=18) male, median age at admission was 38 years [IQR 27-51]. Roughly half the patients had pancolitis at diagnosis (51.4%, n=18). Median disease duration was 9 months [IQR 0-26] and 22.9% (n=8) had previous exposure to biologic therapy. In 34.3% (n=12), ASUC was the initial presentation of UC. Median follow-up was 30 months [IQR 12-51].
Response to corticosteroid therapy was observed in 57.1% (20/35). All the steroid-refractory patients (15/35, 42,9%) responded to rescue therapy (Infliximab n=11; Tacrolimus n=3; Tofacitinib n=1) and avoided colectomy during the hospitalization.
Baseline characteristics were identical between steroid-responsive and steroid-refractory patients, except for a lower median age in corticoid refractory patients (29 years vs 48 years, p=0.02).
Survival analysis was performed and no differences between steroid-responsive and steroid-refractory patients were observed in need for switch of maintenance therapy [during first year (p=0,28) and during complete follow-up (p=0,54)] , need for readmission [during first year (p=0,55) and during complete follow-up (p=0,54)] or need for colectomy [during first year (p=0,09) and during complete follow-up (p=0,79)].

Conclusion

In our cohort of patients with a first episode of ASUC, with the current therapeutic paradigm, patients with steroid refractoriness had similar outcomes as corticosteroid responders. These results suggest that effective and timely therapy can change the natural history of ASUC.

References

1. Festa S, Scribano ML, Pugliese D, Bezzio C, Principi M, Ribaldone DG, Allocca M, Mocci G, Bodini G, Spagnuolo R, Vernia P, Mazzuoli S, Costa F, Barberio B, Cosintino R, Zerboni G, Aratari A, Armuzzi A, Papi C. Long-term outcomes of acute severe ulcerative colitis in the rescue therapy era: A multicentre cohort study. United European Gastroenterol J. 2021 May;9(4):507-516. doi: 10.1177/2050640620977405. Epub 2021 Feb 16. PMID: 33259773; PMCID: PMC8259429.
2. Zafer M, Zhang H, Dwadasi S, Goens D, Paknikar R, Dalal S, Cohen RD, Pekow J, Rubin DT, Sakuraba A, Micic D. A Clinical Predictive Model for One-year Colectomy in Adults Hospitalized for Severe Ulcerative Colitis. Crohns Colitis 360. 2021 Dec 21;4(1):otab082. doi: 10.1093/crocol/otab082. PMID: 36777555; PMCID: PMC9802419.

Introduction

The first-line treatment for patients hospitalized with Acute severe ulcerative colitis (ASUC) is intravenous corticosteroid therapy, but 30% require second-line 'rescue' infliximab (IFX) therapy or colon resection due to incomplete response. Identifying patients with acute severe ulcerative colitis who are refractory to corticosteroid therapy remains challenging, as physicians have no markers to predict non-response to steroids on admission. This study aims to investigate whether the CRP/albumin ratio on days 1 and 3 of hospitalization could predict early response to intravenous steroids.

Aims & Methods

Data from all admissions for acute severe ulcerative colitis over 4 years from January 2019 to December 2022 were retrospectively collected.
All patients initially received intravenous corticosteroids. Demographic, clinical, biological, and endoscopic data were collected; C-reactive protein (CRP) and albumin levels were recorded at baseline and during hospitalization. Receiver operating characteristic statistics were used to determine the optimal stool frequency, Lichtiger index, CRP, albumin, and CRP/albumin ratio (CAR) to predict steroid response.

Results

A total of 81 ASUC patients were admitted. Sixty-six patients (81.5%) were steroid responsive, 8 patients (10%) received rescue IFX and 7 patients (8.6%) required colectomy. By comparing two groups of patients (steroid-responsive and steroid-refractory), baseline stool frequency, Lichtiger index, CRP and CRP/Albumin ratio data didn’t show any significant difference between the two groups. While baseline albumin was lower in the steroid-refractory group (Median 26, IQR 18-36, p=0.041).
Day 3 stool frequency and Lichtiger index were significantly higher in the steroid refractory group (p<0.001).
By receiver operating characteristic statistics, day 3 CAR was a more accurate marker of steroid responsiveness than day 3 CRP or day 3 albumin alone [area under curve=0.911 (P<0.001)]. The optimal CAR to predict response to steroids on day 3 was 2.67 (sensitivity 80%, specificity 91%).

Conclusion

An elevated CRP and low albumin level on day 3 is an early predictor of steroid-refractory ASUC. When combined in a ratio, their predictive ability improves. In patients with predicted steroid nonresponse, early introduction of rescue IFX at this stage may be more effective, before serum albumin falls profoundly.