Adam Cheifetz, MD, on Managing Severe Ulcerative Colitis

Dr Cheifetz, from Beth Israel Deaconess Medical Center in Boston, spoke about the treatment options available for patients with severe ulcerative colitis, from medical management to surgery at the recent Interdisciplinary Autoimmune Summit.
 

Adam Cheifetz, MD, is director of the Center for Inflammatory Bowel Disease at Beth Israel Deaconess Medical Center in Boston, Massachusetts.

TRANSCRIPT:

Dr. Adam Cheifetz: I'm Adam Cheifetz, director of the Center for Inflammatory Bowel Disease at Beth Israel Deaconess Medical Center in Boston.

If you were not able to attend IAS, I just gave a lecture on severe ulcerative colitis. I'd like now to give you a few of my key points, take my 40-minute lecture and put it into about 5 minutes.

I went through a case of severe ulcerative colitis, which, as you know, is quite common. About 25% of patients with ulcerative colitis will present with a severe flare requiring hospitalization. I want to be clear. This is still an emergency. Thinking back, before 1960, severe ulcerative colitis had a mortality rate of 25%.

With the advent of corticosteroids for treating it, it dropped to about 7% with better care, earlier treatments. Nowadays, it's less than 5%, but there still is a mortality rate associated with this, so we should take it seriously.

Almost 20% of patients admitted with severe ulcerative colitis will have surgery, even during that hospitalization. You have to take it seriously. It's a good history, good physical. Early on, you want to get your routine labs, including CRP, albumin. We want to check for latent tuberculosis with a QuantiFERON Gold and hepatitis B.

Don't forget get your stool studies. You need to rule out C. diff. C. difficile is more common in patients with ulcerative colitis and negatively impacts outcomes. You want to get some abdominal imaging, at least a flat plate. If there's any signs of toxicity or fever or concerning abdominal exam, get yourself a CAT scan.

Flexible sigmoidoscopy is also important. It not only establishes the severity of disease, but you also use it to biopsy to rule out CMV. DVT prophylaxis is another important thing not to forget. These patients are at an increased risk of DVT, which, again, increases morbidity and mortality in this group.

Avoid narcotics in these patients, avoid antidiarrheals. The thought is you don't want to tip them over to a toxic megacolon, and you certainly don't want to mask symptoms.

The mainstay of therapy has been and remains intravenous corticosteroids, the equivalent of methylprednisolone, 60 milligrams is all you need. Higher doses have not been shown to be more effective.

Fortunately, IV steroids are effective in about two-thirds of the patients. They respond, you can get them home, and you can get them on to a biologic that's going to maintain remission.

If a patient isn't responding at day three, you should know. If at day three, if a patient has more than 8 bowel movements a day or their CRP is greater than 45 and they're still having 2 bowel movements, that tells me their risk of failure is 85%. That's the Oxford index. I like to keep things simple. That's the one thing I can memorize, and that's one thing I'll use.

If at day 3 they hit that, now you're thinking I'm definitely getting colorectal surgery involved, if they haven't always been. I'm going to think about rescue therapy. In that case, I'm thinking infliximab or cyclosporine.

Don't forget about surgery. Surgery is an option. This decision should be made early. By day 3, you should be talking about it. It's a team approach and shared decision-making with the patient.

A lot of the talk was on infliximab versus cyclosporine, risks and benefits of each of those. Most of you are very comfortable with infliximab, so I did focus on that. If you initiate someone on infliximab and they do well, you can then maintain them on infliximab. You all know the risks of infliximab. I won't go over those.

Cyclosporine, if you're comfortable with using it, is a good option. They've been shown to be basically equivalent. Remember, if you're going to use cyclosporine, you cannot maintain them on cyclosporine. You either need to move them onto an immunomodulator, like 6-mercaptopurine. Or there's some data now moving them onto vedolizumab as an option and certainly considering some of the other biologics.

Don't forget about surgery. Don't think of surgery as a failure of medical therapy. Think of it as another option. If you're talking about surgery, really go into what it's like to have an ileal pouch anal anastomosis with your patient.

It's about 5 to 6 bowel movements a day, 1 or 2 bowel movements overnight. Go over the risk of leakage and incontinence, and particularly go over the increased risk of lower rate of fecundity in patients who are female of childbearing age.

Regardless, it is a good quality of life, whether the patient has an ileal pouch-anal anastomosis, or whether they have a total proctocolectomy and an ileostomy. It's important to remember about 40% to 50% of patients will require surgery within 5 years. It's not a bad thing to bring up at this point and important.

Hope you learned something, and I hope to see you next year at IAS in person. Thank you.