P355 Examining maintenance care following infliximab salvage therapy for acute severe ulcerative colitis
D. Seah*1, 2, M. Choy1, 2, 3, A. Gorelik4, F. Macrae5, M. Sparrow6, W.R. Connell3, G. Moore7, D. Van Langenberg8, P. De Cruz1, 2
1Austin Health, Department of Gastroenterology, Melbourne, Australia, 2University of Melbourne, Department of Medicine, Melbourne, Australia, 3St Vincent’s Hospital, Department of Gastroenterology, 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
Although infliximab (IFX) salvage therapy has improved short-term colectomy rates in acute severe ulcerative colitis (ASUC), long-term colectomy rates remain high. The management of ASUC has focused on induction of remission with less attention given to maintenance therapy. Data supporting the optimal maintenance drug therapy and strategy to monitor ongoing response are limited. We aimed to evaluate maintenance and monitoring strategies employed in patients post IFX induction therapy.
Patients in 6 Australian tertiary centres treated with IFX for steroid-refractory ASUC between April 2014 and May 2015 were identified via hospital IBD and pharmacy databases. Patients were followed-up for 1 year with clinical data over 12 months recorded.
In total, 41 patients were identified: 2/41 (5%) patients underwent colectomy before discharge. The overall colectomy rate at 3 and 12 months was 5/37 (14%) and 10/24 (42%), respectively. 49% (20/41) were on an immunomodulator (IM) on admission. Patients were treated maintenance therapy including aminosalicylates and thiopurines, and scheduled IFX was observed in 30/39 (77%), 31/39 (80%), and 19/39 (49%), respectively. Further, 58% (11/19) of scheduled IFX patients were previously on an IM; 36% (14/39) were maintained on combination thiopurine and IFX. The colectomy rate was 5/26 (19%) in those maintained on a thiopurine, as compared with 4/8 (50%) amongst those who did not receive thiopurine (p = 0.16), and 4/19 (21%) for patients who had IFX maintenance therapy compared with 5/15 (33%) in those who did not (p = 0.46). Colectomy-free survival at 3 months with and without thiopurine maintenance was 96% (26/27) vs 75% (6/8) (p = 0.12). No significant difference in colectomy rates was found between prior IM use vs IM naivety (31% vs 55%; p = 0.41) or combination IFX and thiopurine therapy vs thiopurine alone (14% vs 13%; p = 1.00). For monitoring during maintenance, post-discharge, thiopurine metabolites were monitored in 15/35 (43%); faecal calprotectin in 11/34 (32%); and serum IFX levels in 4/34 (12%). In addition, 20/31 (65%) patients had an endoscopic evaluation after IFX salvage with median time to first endoscopy of 116 days (IQR 77–223). Use of these monitoring strategies was not associated with a significant difference in colectomy rate.
Following IFX induction therapy for ASUC, the uptake of maintenance therapy in this cohort and strategies to monitor ongoing response were variable. Thiopurine maintenance was associated with a trend towards a reduced colectomy rate; however, no significant difference in outcomes was observed between those on thiopurine monotherapy vs combination IFX and thiopurine. These data combined with a paucity of available guidelines suggest that the optimal maintenance and monitoring strategy post IFX salvage therapy remains to be defined.