Introduction
Acute severe ulcerative colitis (ASUC) is a medical emergency requiring hospitalisation. Overtime, there has been an increasing number of biologic and non-biologic treatment options available to induce and maintain disease remission. A previous study found no significant difference in length of stay or colectomy rates for those on biologic or small molecule therapy prior to admission compared to those who were not on advanced ulcerative colitis (UC) therapies, but found they had higher rates of surgical consultation and 90-day readmission rates.1 We aimed to evaluate the preadmission medications patients were receiving at time of ASUC presentation, and to determine whether maintenance biologic and small molecule therapy had an effect on patient outcomes, including need for rescue therapy, colectomy, total parental nutrition (TPN), length of stay (LOS), readmission rates and mortality.
Aims & Methods
A retrospective review was conducted on all ASUC presentations to a quaternary Sydney hospital over a 10-year period. A modified Truelove and Witts’ criteria was used to define ASUC.Data was collected on preadmission UC medications, including aminosalicylates, thiopurines, steroids and advanced UC therapies, including biologics and small molecule inhibitors. Outcomes assessed included need for biologic rescue therapy, colectomy, TPN, length of stay, 30- and 90-day readmission rates, and 30- and 90-day mortality rate.
Results
A total of 172 ASUC presentations were identified. Of these, 143 presentations (83%) were patients with existing diagnosis of UC. Pre-admission medications in these patients included aminosalicylates (62%, n=89), thiopurines (25%, n=36), steroids (61%, n=87), biologics (17%, n=25), and small molecule inhibitors (2%, n=3). Patients taking aminosalicylates as maintenance therapy had significantly lower rates of need for rescue therapy (32% vs 51%, p=0.015). Patients on aminosalicylates-only had lower rates of 90-day readmission compared to those on both aminosalicylates and additional advanced UC therapies (0% vs 31%, p=0.007). There was no significant difference in need for rescue therapy for those on other maintenance therapies. Patients who presented on prednisolone <20 mg/d had a significantly higher rate of 90-day readmission compared to those on a dose ≥20mg (47% vs 13%, p=0.004). Those on biologic maintenance therapy had significantly higher rates of TPN use, colectomy, 90-day readmission, 30-and 90-day mortality and mean length of stay (Table 1). Patients on small molecule inhibitors had a shorter length of stay (7±1 vs 11±9.2 days, p=0.001), but no difference in other treatment outcomes.
| | | Treatment outcomes |
| | | Rescue therapy | TPN | Colectomy | Readmission 30 days | Readmission 90 days | Death 30 days | Death 90 days | Mean LOS (days) |
| | | Yes | No | Yes | No | Yes | No | Yes | No | Yes | No | Yes | No | Yes | No |
| |
| Biologic use | Yes
(n=25) | 12 (48%) | 13 (52%) | 8 (32%) | 17 (68%) | 10 (40%) | 15 (60%) | 3 (13%) | 20 (87%) | 10 (43%) | 13 (57%) | 2 (8%) | 23 (92%) | 2 (8%) | 23 (92%) | 15.6 ± 13.1 | |
No
(n=118) | 44 (37%) | 74 (63%) | 10 (9%) | 108 (91%) | 6 (5%) | 112 (95%) | 18 (15%) | 100 (85%) | 20 (20%) | 98 (80%) | 1 (1%) | 117 (99%) | 1 (1%) | 117 (99%) | 9.9 ± 7.8 | |
| p-value | | p=0.319 | p=0.001* | p<0.001* | p=0.785 | p=0.004* | p=0.023* | p=0.023* | p=0.045* |
Conclusion
Patients with pre-existing diagnosis of UC on maintenance biologic therapy who presented with ASUC were more likely to require TPN, colectomy, 90-day readmission, 30-and 90-day mortality and longer length of stay. Patients on aminosalicylates-only had lower rates of 90-day readmission. Our study findings may reflect that patients on advanced outpatient UC therapies have a more severe phenotype translating to a more severe ASUC admission course. More research is needed to predict such markers of severity.
References
1. Sabrie, N., Jogendran, M., Jogendran, R. & Targownik, L.E. Outcomes of patients admitted with acute, severe ulcerative colitis on biologic therapy: a retrospective analysis from a tertiary referral hospital. Journal of the Canadian Association of Gastroenterology 7, 306-311 (2024).
