P313 Comparison of accelerated infliximab induction versus standard induction treatment in acute severe ulcerative colitis
M. Choy*1, 2, 3, D. Seah1, 3, A. Gorelik4, F. Macrae5, M. Sparrow6, W. R. Connell2, G. Moore7, D. Van Langenberg8, P. De Cruz1, 3
1Austin Health, Department of Gastroenterology, Melbourne, Australia, 2St Vincent’s Hospital, Department of Gastroenterology, Melbourne, Australia, 3University of Melbourne, Department of Medicine, Melbourne, Australia, 4Royal Melbourne Hospital, Melbourne EpiCentre, Melbourne, Australia, 5Royal Melbourne Hospital, Department of Gastroenterology, Melbourne, Australia, 6The Alfred Hospital, Department of Gastroenterology, Melbourne, Australia, 7Monash Health, Department of Gastroenterology, Melbourne, Australia, 8Eastern Health, Department of Gastroenterology, Melbourne, Australia
Notably, 50% of patients with acute severe ulcerative colitis (ASUC) undergo colectomy within 3 years of infliximab salvage therapy. Elevated CRP, CRP/albumin ratio, and low albumin have been identified as predictors of colectomy. Recent data suggest that an accelerated infliximab induction strategy of 3x5 mg/kg doses within 4 weeks may reduce colectomy rates, as compared with standard induction over 6 weeks. However, it remains unclear as to which patients most benefit from such a strategy. We aimed to investigate whether accelerated infliximab induction improved outcomes in ASUC, and to identify predictors of colectomy.
Patients in 6 Australian tertiary centres treated with infliximab for steroid-refractory ASUC between April 2014 and May 2015 were identified through hospital IBD and pharmacy databases. Infliximab salvage strategy was determined individually by treating clinicians. Clinical data at baseline, induction, and 3 and 12 months were recorded, and regression analysis was performed.
Identified were 41 patients: 31.7% (13/41) were female, with a mean age of 38 ± 14 years. Median disease duration was 33.1 months (IQR 18.5–79.3), and 48.8% (20/41) were on immunodulators (IM) at admission. At time of induction, mean albumin was 25.2 ± 5.6 g/L, and median CRP 24 mg/L (IQR 6–42). The overall colectomy rate at 3 and 12 months was 13.5% (5/37) and 41.7% (10/24), respectively. Median time to colectomy was 69 days (IQR 26–131). Of those who completed 3-dose induction, 74.3% (26/35) received standard induction (St-IFX) over 6 weeks; 25.7% (9/35) received accelerated infliximab (A-IFX) induction within a median of 20 days (IQR 17–26).
Patients who had A-IFX had a significantly higher CRP and CRP/Albumin ratio at baseline compared with St-IFX (CRP 82 mg/L [IQR 63–289] vs 28 mg/L ([QR 13–54], p = 0.01; CRP/alb 3.6 [IQR 2.1–12.6] vs 1.0 [IQR 0.5–2.0], p = 0.02). A-IFX patients also had a higher induction CRP/alb compared with St-IFX (2.0 [IQR 2–5] vs 0.6 [IQR 0.3–1.6]), p = 0.01). Despite these differences, the colectomy rate for A-IFX was similar to St-IFX (22.2% vs 29.6%, p = 1.00) with no difference at 3 or 12 months. Prior IM use, CRP, and albumin were not found to be significant predictors of colectomy in this cohort.
In this cohort of ASUC patients, accelerated infliximab induction was used in those with biochemically more severe disease compared with standard induction. Despite expectations that high CRP and CRP/albumin ratios are associated with an increased colectomy rate, we found no difference, suggesting that a more intensive treatment regimen may be required to improve outcomes in high-risk patients. Prospective exploration of accelerated infliximab strategies is required to determine further predictors of response and develop appropriate tailored therapies.