P330. Cyclosporin A as rescue therapy for steroid-refractory acute severe ulcerative colitis: Oral administration is as effective as intravenous
P. Kumar1, D. Rowbotham1
1Auckland City Hospital, Gastroenterology & Hepatology, Auckland, New Zealand
Background: Intravenous (IV) cyclosporin A (CSA) is an effective rescue therapy for severe ulcerative colitis (UC) refractory to IV corticosteroids, with the aim of preventing emergency colectomy. With newer oral CSA formulation (rapidly absorbed and high bioavailability), the indications for IV CSA over oral administration are less apparent. Reported success rates with IV CSA show an average of 79% of patients avoiding colectomy in the short term. Published literature on the sole use of oral CSA in steroid-refractory acute severe UC is relatively sparse. In our centre we have been using oral CSA in this setting for some years commencing at a dose of 7 mg/kg, adjusting according to blood levels and treating for 3 months. We initiate an immunomodulator early (if not already on one). The aim of this study was to evaluate whether use of oral CSA in this way is as effective as published data on IV CSA in the prevention of acute colectomy.
Methods: Retrospective case note survey of all adult patients admitted to Auckland City Hospital with steroid-refractory acute severe UC who were commenced on oral CSA from September 1999 through to June 2010.
Results: A total of 41 patients were identified, 5 of whom received two courses of oral CSA (interval between dosing of 5, 7, 8, 23 and 72 months respectively). Hence we analysed data from a cohort of 46 uses of oral CSA. 67.4% were already taking oral steroids on admission, and 32.6% were already established on a thiopurine. Median number of days on IV steroids prior to starting oral CSA was 3. 11 patients (23.9%) failed to respond to oral CSA and progressed to surgery in the short term (during admission or within 7 days of discharge). Hence 76.1% of patients treated with oral CSA avoided colectomy in the short term. 6 further patients (13.0%) underwent colectomy within 6 months of discharge (2 urgent resections, 4 elective). Median length of follow-up is 71 months for the 29 patients who did not require colectomy within the first 6 months. Of these, 10 have since undergone planned colectomy during follow up, with a median time to surgery of 29.5 months after commencement of oral CSA. Only 1 patient stopped CSA due to side effects (abdominal discomfort), otherwise the CSA was well tolerated.
Conclusions: Oral CSA is an effective and well tolerated therapy to rescue patients with steroid-refractory acute severe UC and, in our centre, is as effective at preventing urgent colectomy as published data on IV CSA. The majority of these benefits are maintained long term.