Dr Syal goes over his talk at the April 30 virtual AIBD Regionals meeting on the management of patients with severe ulcerative colitis.

Gaurav Syal, MD, is an Assistant Professor of Medicine at Cedars-Sinai Medical Center, Los Angeles. 


TRANSCRIPT

Gaurav Syal, MD:
Hello, everybody. My name is Gaurav Syal. I'm an Assistant Professor of Medicine and a gastroenterologist focusing on inflammatory bowel disease at Cedar Sinai Medical Center in Los Angeles. My talk about severe ulcerative colitis management, I want to highlight a few key takeaway points from that talk. Ulcerative colitis is a very common disease. And a lot of the patients who are diagnosed with ulcerative colitis, present initially, or subsequently in their disease course, with severe ulcerative colitis. So, I think the gastroenterologist should know how to recognize a severe ulcerative colitis flare, so we talk about that. And the next important point is that the primary treatment for severe ulcerative colitis is steroids. So IV steroids, whether it is Methylprednisolone or an equivalent or of that, they form the backbone of treatment of severe ulcerative colitis.

There are a few important things that I think we should remember and recognize. One is: when is the right time to start steroids? That's usually once the patient presents and you have done the initial investigations to rule out an infection. Most common would be enteric infections like C. diff infection. That's fairly common in patients with ulcerative colitis. And so once you've done that, you start IV steroids. And the next important thing is, how much steroids you need to start, what dose? And the studies have shown that generally, around 40 to 60 milligram total dose in a day is adequate. There's no significant benefit of going higher than that.

Next question is: how long do we treat patients with IV steroids? And when should we start assessing response to them? So again, there is good data on this topic that the assessment of response should be done generally around three to five days after the patients have been on the IV steroids.

And there are several ways to assess response. There are several indices. We talked about a few of them, but the most commonly used and perhaps the easiest is the Travis index or also called Oxford criteria. Basically, it just looks at the number of bowel movements at baseline and... at three to five days, and the decline in CRP from the baseline and compare it to three to five days at CRP. And, based on those two parameters, there have been studies which show that you can fairly accurately identify patients who are... have an adequate response from those who do not. Now, patients who do have an adequate response are they are transitioned to oral steroids and they can home...they can go home. The patients who do not have an adequate response to IV steroids are at a very high risk of colectomy. And those patients are the ones where one, we should involve colorectal surgery early, and two, think about other medical treatment options.

And those are rescue treatment options. There are two such traditional medical rescue treatment options for severe ulcerative colitis in the form of cyclosporine and infliximab. Both of them have equivalent effectiveness and relatively equivalent safety. So which one you choose largely should depend on your experience with that. So if a center is more experienced with cyclosporine then perhaps they would prefer that, and the same for infliximab. The other important thing in making that determination is the patient's prior medication history. So for example, if a patient has in the past tried infliximab for ulcerative colitis, then infliximab is not a good option and cyclosporine may be preferred. There is a new emerging rescue treatment option in the form of tofacitinib. There are some studies which have shown that a high dose tofacitinib can rescue patients from colectomy in the situation of IV steroid refractory ulcerative colitis. But there is only emerging data on that, so I think we'll need more data before that becomes more widely accepted.

The last point I want to highlight is that even though we talk a lot about the primary management of severe ulcerative colitis with steroids and rescue medications, infliximab, cyclosporine, and tofacitinib, I think there are other parts to managing these patients when they're in the hospital which are equally important. And a few of those are frequently overlooked so I think that's another thing to highlight. One, that these patients are at quite a high risk of venous thromboembolism, so they can develop blood clots. And these patients, unless there is a clear contraindication should be receiving pharmacological prophylaxis against thromboembolism. Now, most of these patients are going to have some blood in the stool to some degree, and that generally should not preclude them from receiving venous thromboembolism, because there are studies which have shown that the risk of major bleeding or minor bleeding does not go up, even in these patients when they're treated with heparin.

The other important thing is there is no role for antibiotics in addition to steroids, unless there is a clear infection documented. And the third and very important point is that the patients, they usually either are already malnourished or they do lose a lot of weight and become malnourished during the hospitalization or during the episode of severe ulcerative colitis. And nutritional support is paramount in overall management of these patients. There is some data that patients who are nutritionally adequate, they might do better. We know that low albumin, which could be a marker of nutrition, is associated with poor response to infliximab for example, so diet should not be ignored in these patients. And the best way to feed these patients is to feed them by mouth. There is no benefit of using enteral nutrition or TPN. In fact, TPN would be associated with higher risk of complications and is not associated with better nutritional outcomes. So those are the few key takeaway points that I want to highlight from my thought on severe ulcerative colitis. Thank you for your attention.