Long‐term outcomes of acute severe ulcerative colitis in the rescue therapy era: A multicentre cohort study

Background The long‐term course of ulcerative colitis after a severe attack is poorly understood. Second‐line rescue therapy with cyclosporine or infliximab is effective for reducing short‐term colectomy but the impact in the long‐term is controversial. Objective The purpose of this study was to eva...

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Published in:	United European gastroenterology journal 2021-05, Vol.9 (4), p.507-516
Main Authors:	Festa, Stefano, Scribano, Maria L., Pugliese, Daniela, Bezzio, Cristina, Principi, Mariabeatrice, Ribaldone, Davide G., Allocca, Mariangela, Mocci, Giammarco, Bodini, Giorgia, Spagnuolo, Rocco, Vernia, Piero, Mazzuoli, Silvia, Costa, Francesco, Barberio, Brigida, Cosintino, Rocco, Zerboni, Giulia, Aratari, Annalisa, Armuzzi, Alessandro, Papi, Claudio
Format:	Article
Language:	eng
Subjects:	acute severe ulcerative colitis Administration, Intravenous Adult Colectomy Colitis, Ulcerative - drug therapy Colitis, Ulcerative - surgery Female Follow-Up Studies Glucocorticoids - administration & dosage Glucocorticoids - therapeutic use hospitalisation Hospitalization Humans Inflammatory Bowel Disease infliximab Infliximab - therapeutic use Male Methylprednisolone - administration & dosage Methylprednisolone - therapeutic use Middle Aged Original Recurrence rescue therapy Retrospective Studies Risk Factors Treatment Outcome Tumor Necrosis Factor Inhibitors - therapeutic use Tumor Necrosis Factor-alpha - antagonists & inhibitors
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Summary:	Background The long‐term course of ulcerative colitis after a severe attack is poorly understood. Second‐line rescue therapy with cyclosporine or infliximab is effective for reducing short‐term colectomy but the impact in the long‐term is controversial. Objective The purpose of this study was to evaluate the long‐term course of acute severe ulcerative colitis patients who avoid early colectomy either because of response to steroids or rescue therapy. Methods This was a multicentre retrospective cohort study of adult patients with acute severe ulcerative colitis admitted to Italian inflammatory bowel disease referral centres from 2005 to 2017. All patients received intravenous steroids, and those who did not respond received either rescue therapy or colectomy. For patients who avoided early colectomy (within 3 months from the index attack), we recorded the date of colectomy, last follow‐up visit or death. The primary end‐point was long‐term colectomy rate in patients avoiding early colectomy. Results From the included 372 patients with acute severe ulcerative colitis, 337 (90.6%) avoided early colectomy. From those, 60.5% were responsive to steroids and 39.5% to the rescue therapy. Median follow‐up was 44 months (interquartile range, 21–85). Colectomy‐free survival probability was 93.5%, 81.5% and 79.4% at 1, 3 and 5 years, respectively. Colectomy risk was higher among rescue therapy users than in steroid‐responders (log‐rank test, p = 0.02). At multivariate analysis response to steroids was independently associated with a lower risk of long‐term colectomy (adjusted odds ratio = 0.5; 95% confidence interval, 0.2–0.8), while previous exposure to antitumour necrosis factor‐α agents was associated with an increased risk (adjusted odds ratio = 3.0; 95% confidence interval, 1.5–5.7). Approximately 50% of patients required additional therapy or new hospitalisation within 5 years due to a recurrent flare. Death occurred in three patients (0.9%). Conclusions Patients with acute severe ulcerative colitis avoiding early colectomy are at risk of long‐term colectomy, especially if previously exposed to antitumour necrosis factor‐α agents or if rescue therapy during the acute attack was required because of steroid refractoriness. Key Summary In ulcerative colitis patients experiencing a severe attack, the risk of long‐term colectomy is relevant even in patients who initially respond to medical therapy. This risk is significantly higher in patients who need rescue therap
ISSN:	2050-6406 2050-6414