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P308. Treatment of corticosteroid naive children and adolescents with ulcerative colitis by adsorptive depletion of myeloid lineage leucocytes as monotherapy or in combination with low dose prednisolone after failure of first-line medications

T. Tanaka, S. Sugiyama, H. Goishi, T. Kajihara, M. Akagi, T. Miura, Akitsu Hospital, Gastroenterology, Hiroshima, Japan

Background

Given that patients with active ulcerative colitis (UC) have elevated and activated myeloid lineage leucocytes including the CD14+CD16+ monocyte phenotype known to release TNF-α, selective depletion of these leucocytes by granulocyte and monocyte adsorption (GMA) should be therapeutic in UC patients. This strategy is most relevant in growing young patients. This study was to evaluate the efficacy of GMA in children and adolescents with active UC in whom conventional first-line medications had failed to induce remission.

Methods

In a single centre setting, between 2010 and 2013, a total of 25 consecutive children and adolescents, age 11–19 years, body weight 33–55 kg were given mesalazine or sulphasalazine as a first-line medication. Eighteen patients relapsed or did not respond and received GMA with the Adacolumn, 2 sessions in the first week, then weekly, up to 11 sessions. Patients who achieved a decrease of ≥5 in the clinical activity index (CAI) were to continue with GMA, while non-responders were to receive 0.5 to 1.0 mg/kg/day prednisolone (PSL) plus additional GMA sessions. At entry and week 12, patients were clinically and endoscopically evaluated, allowing each patient to serve as her/his own control.

Results

At entry, all 25 patients were corticosteroid naïve and none had deep colonic UC lesions together with extensive loss of the mucosal tissue at the affected sites. Seven patients achieved remission with the first-line medications and did not receive GMA. Six patients did not respond well to the first 5 GMA sessions and received PSL plus GMA, while 12 patients responded to the first 5 GMA sessions and received additional sessions. At entry, the average CAI was 14.1±0.4, range 11–17, and the average endoscopic index was 9.2±0.3, range 7–11. The corresponding values at week 12 were 2.1±0.2, range 1–4 (P < 0.001) and 2.4±0.2, range 1–4 (P < 0.001). PSL was tapered to 0 mg within 3 months. Therefore, at week 12, all 25 patients had achieved clinical remission, majority with mucosal healing (complete remission).

Conclusion

GMA in patients with deep ulcers together with extensive loss of the mucosal tissue (a major GMA non-responder feature) has not been associated with adequate efficacy. However, in this study, GMA in young corticosteroid naïve patients with active UC refractory to the first-line medications was associated with clinical remission and mucosal healing, while in non-responders to GMA monotherapy, addition of a low dose PSL enhanced the efficacy of GMA and tapering of the PSL dose was not associated with UC relapse. Therefore, the majority of young steroid naïve UC patients who fail to respond to the first-line medication should respond to GMA and be spared from pharmacological intervention.