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P439. Management and outcome of severe attacks of ulcerative colitis in the era of biologicals

J. Llaó1, J.E. Naves2, A. Ruiz-Cerulla3, J. Gordillo1, M. Mañosa4, S. Maisterra3, E. Cabré4, E. Garcia-Planella1, J. Guardiola3, E. Domènech4, 1Hospital Santa Creu i Sant Pau, Gastroenterology, Barcelona, Spain, 2Hospital Universitari Germans Trias I Pujol, Dept. of Gastroenterology, Badalona, Spain, 3Hospital Universitari Bellvitge-IDIBELL, Gastroenterology, L'Hospitalet de Llobregat, Spain, 4Hospital Universitari Germans Trias I Pujol-CIBEREHD, Dept. of Gastroenterology, Badalona, Spain

Background

The availability of predictors of response to corticosteroids (CS) and the use of cyclosporine and infliximab as rescue therapies should have modified the management and outcome of severe ulcerative colitis (SUC). Aim: To describe the current need of rescue therapies and colectomy in CS-treated SUC.

Methods

All UC patients admitted to three University hospitals between January 2005 and December 2011 were identified from electronic databases. Disease severity was defined according to the Montreal classification, and only patients with SUC treated with intravenous CS were included. Main end-points were: initial CS efficacy (defined as mild or inactive UC activity assessed by Montreal Classification at day 7 after starting intravenous CS without a rescue therapy), medical rescue therapy requirements, colectomy rate, and long-term clinical outcome (steroid dependency, colectomy).

Results

A total of 62 flares were included (57 patients), 18% in active smokers, 70% extensive disease, 33% while on azathioprine maintenance therapy, and 22% previously treated for the same flare with oral GCS. Median C-reactive protein concentration at the beginning of intravenous CS was 99.5 mg/L (IQR, 55.5–163). Initial response of CS was achieved in 50% and 43% of flares required medical rescue therapies (12 cyclosporine, 15 infliximab) and one patient needed colectomy. Median time between the beginning of intravenous CS and rescue therapy was 7 days (IQR, 4–9), without differences between cyclosporine and infliximab-treated patients. The initial treatment with oral CS was the only risk factor (P = 0.017) and to be a former smoker the only protective factor (P = 0.003) for needing rescue therapies. During follow-up, 38% of those patients responding to CS developed steroid-dependency and 4 patients who needed a rescue treatment during admission underwent colectomy. The initial treatment with oral GCS for the index flare, the failure of intravenous CS and the need of rescue therapy were associated with colectomy, but the initial treatment with oral CS was the only independent predictive factor of colectomy in the multivariate analysis (P < 0.0001).

Conclusion

The efficacy of intravenous CS in SUC is 50%, but the colectomy rate is <10% in the short and long-term. Patients worsening after oral CS are at a higher risk for needing rescue therapies and colectomy.