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P349 Consensus Statements on the Management of Acute Severe Ulcerative Colitis

J.-H. Chen1, C. Corte1, V. Kariyawasam2, N. Moran1, P. Gounder1, G. Collins1, S. Connor3, T.W. Lee4, A. Walsh5, C.E. Koh6, 7, J. Chang1, S. Paramsothy8, S. Tattersall9, D.A. Lemberg10, 11, A. McLachlan12, 13, G. Moore14, J. Andrews15, R. Leong*1

1Concord Repatriation General Hospital, Gastroenterology & Hepatology, Sydney, Australia, 2Blacktown Hospital, Gastroenterology & Hepatology, Sydney, Australia, 3Liverpool Hospital, Gastroenterology & Hepatology, Sydney, Australia, 4Wollongong Hospital, Gastroenterology & Hepatology, Wollongong, Australia, 5St. Vincent Hospital, Gastroenterology & Hepatology, Sydney, Australia, 6Royal Prince Alfred Hospital, Colon & Rectal Surgery, Sydney, Australia, 7Royal Prince Alfred Hospital, Surgical Outcomes Research Centre, Sydney, Australia, 8University of New South Wales, St Vincent's Clinical School, Faculty of Medicine, Sydney, Australia, 9Ryde Hospital, Gastroenterology, Sydney, Australia, 10Sydney Children's Hospital, Paediatric Gastroenterology, Sydney, Australia, 11University of New South Wales, Woman's and Children's Health, Sydney, Australia, 12The University of Sydney, Faculty of Pharmacy, Sydney, Australia, 13Concord Repatriation General Hospital, Centres for Education and Research on Ageing, Sydney, Australia, 14Monash University & Monash Health, Gastroenterology & Hepatology, Clayton, Melbourne, Australia, 15Royal Adelaide Hospital, Gastroenterology and Hepatology, Adelaide, Australia

Background

Acute severe ulcerative colitis (ASUC) is a potentially life-threatening condition affecting 15% of UC patients. The mortality rate has improved from 24% prior to corticosteroids to 2.9%. Treatment guidelines assist in timely diagnosis and initiation of treatment. However, there are no current guidelines that exclusively aid the management of ASUC. Our aim was to develop consensus guidelines on the diagnosis and management of ASUC.

Methods

The Delphi method was used in the development of the consensus statements. A steering committee generated the statements of interest. 80% or more agreement without or with only minor reservation determined acceptance of statements. Three rounds of anonymous voting were carried out to achieve the final Results. Evidence level and recommendation grade, according to the National Health and Medical Research Council (NHMRC) guideline, were endorsed following further discussion.

Results

A total of 33 statements were grouped into 16 themes covering definition, treatment targets, investigations, first-line treatment, indications and options for second-line therapy, maintenance therapy, DVT prophylaxis, nutrition, pharmacy, pregnancy, and opportunistic infections. From 22 multi-disciplinary clinicians, there was 100% agreement for 24 out of 33 statements; 80-99% for 6 statements; and 3 statements were rejected. The rejected statements involved prolonged DVT prophylaxis after hospital discharge; infliximab dosing based on trough level; and restricted use of thiopurines in EBV-naive young patients. Important translatable outcomes include the paucity of evidence of occupational health and safety risks from casual anti-TNF exposure and that all ASUC therapies be readily available for prompt emergency dispensing. Dose intensification of infliximab either by shorter dosing interval or higher dosage can be considered, but further studies are needed to definitively establish the benefit of this practice. Management of ASUC in pregnant women should be no different to non-pregnant patients, including the use of infliximab in the third trimester, as the previous concern of increased infant infection has been shown to be absent in the latest large prospective cohort study of pregnant women.

Conclusion

These are the first comprehensive consensus guidelines specific to ASUC, containing the latest evidence of emerging areas of therapy, as well as detailed discussion of areas previously addressed in other major guidelines. The endorsed statements are expected to improve and harmonise management and provide auditable quality assessments.