Acute Severe Ulcerative Colitis: Review of Management and Emerging Treatments

Authors

  • Natasha Klemm, MD Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, BC.
  • Yvette Leung, MD Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, BC.

DOI:

https://doi.org/10.58931/cibdt.2024.2229

Abstract

Acute severe ulcerative colitis (ASUC) is a medical emergency, with an overall mortality rate of 1%. Patients with ulcerative colitis (UC) have a 20–25% rate of severe exacerbation requiring hospitalization for urgent medical treatment and surgical consideration. The rate of re-hospitalization for recurrent ASUC is 34.4%, and it typically occurs within 24 months of the index admission. Treatment requires a patient-centred multidisciplinary approach that includes gastroenterology, colorectal surgery, and nutrition support, with the goal of minimizing disease complications, adverse events of treatment, and healthcare costs.6 Clinicians and patients have an increasing number of treatment options and additional safety issues to consider. We review the current approach to management and summarize emerging data on the use of novel agents to treat ASUC. 

Author Biographies

Natasha Klemm, MD, Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, BC.

Dr. Klemm is a fifth-year gastroenterology resident at the University of British Columbia. She completed her medical school training at the University of Manitoba in 2019 and internal medicine residency at the University of British Columbia in 2022. During her training, she has published on a variety of gastroenterology topics. She has a special interest in inflammatory bowel disease and following completion of her residency, will undertake an advanced IBD fellowship at the Beth Israel Deaconess Medical Center in Boston. 

Yvette Leung, MD, Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, BC.

Dr. Yvette Leung graduated from University of Calgary Cumming School of Medicine and completed her internal medicine residency at the University of British Columbia. She subsequently completed her gastroenterology fellowship at the University of Calgary and an advanced IBD fellowship at the University of Chicago. She started as clinical faculty at the University of Calgary IBD Clinic and moved in 2016 to join the IBD Centre of BC in Vancouver British Columbia. She leads the IBD and Pregnancy Clinic and is an active clinical trials investigator. When she is not working she enjoys the great outdoors on the North Shore with her husband and two kids. 

References

Dong C, Metzger M, Holsbø E, Perduca V, Carbonnel F. Systematic review with meta-analysis: mortality in acute severe ulcerative colitis. Aliment Pharmacol Ther. 2020;51(1):8-33. doi:10.1111/apt.15592 DOI: https://doi.org/10.1111/apt.15592

Nakase H. Acute severe ulcerative colitis: optimal strategies for drug therapy. Gut Liver. 2023;17(1):49-57. doi:10.5009/gnl220017 DOI: https://doi.org/10.5009/gnl220017

Travis SP, Farrant JM, Ricketts C, Nolan DJ, Mortensen NM, Kettlewell MG, et al. Predicting outcome in severe ulcerative colitis. Gut. 1996;38(6):905-910. doi:10.1136/gut.38.6.905 DOI: https://doi.org/10.1136/gut.38.6.905

Truelove SC, Witts LJ. Cortisone in ulcerative colitis; preliminary report on a therapeutic trial. Br Med J. 1954;2(4884):375-378. doi:10.1136/bmj.2.4884.375 DOI: https://doi.org/10.1136/bmj.2.4884.375

Festa S, Scribano ML, Pugliese D, Bezzio C, Principi M, Ribaldone DG, et al. Long-term outcomes of acute severe ulcerative colitis in the rescue therapy era: a multicentre cohort study. United European Gastroenterol J. 2021;9(4):507-516. doi:10.1177/2050640620977405 DOI: https://doi.org/10.1177/2050640620977405

Kaplan GG, Kuenzig ME, Windsor JW, Bernstein CN, Bitton A, Coward S, et al. The 2023 impact of inflammatory bowel disease in Canada: COVID-19 and IBD. J Can Assoc Gastroenterol. 2023;6(Suppl 2):S76-s82.doi:10.1093/jcag/gwad019 DOI: https://doi.org/10.1093/jcag/gwad019

Gupta V, Mohsen W, Chapman TP, Satsangi J. Predicting outcome in acute severe colitis-controversies in clinical practice in 2021. J Crohns Colitis. 2021;15(7):1211-1221. doi:10.1093/ecco-jcc/jjaa265 DOI: https://doi.org/10.1093/ecco-jcc/jjaa265

Adams A, Gupta V, Mohsen W, Chapman TP, Subhaharan D, Kakkadasam Ramaswamy P, et al. Early management of acute severe UC in the biologics era: development and international validation of a prognostic clinical index to predict steroid response. Gut. 2023;72(3):433-442.doi:10.1136/gutjnl-2022-327533 DOI: https://doi.org/10.1136/gutjnl-2022-327533

Feuerstein JD, Isaacs KL, Schneider Y, Siddique SM, Falck-Ytter Y, Singh S. AGA Clinical Practice Guidelines on the management of moderate to severe ulcerative colitis. Gastroenterology. 2020;158(5):1450-1461.doi:10.1053/j.gastro.2020.01.006 DOI: https://doi.org/10.1053/j.gastro.2020.01.006

Bitton A, Buie D, Enns R, Feagan BG, Jones JL, Marshall JK, et al. Treatment of hospitalized adult patients with severe ulcerative colitis: Toronto consensus statements. Am J Gastroenterol. 2012;107(2):179-194; author reply 195. doi:10.1038/ajg.2011.386 DOI: https://doi.org/10.1038/ajg.2011.386

Berry SK, Takakura W, Bresee C, Melmed GY. Pain in Inflammatory bowel disease is not improved during hospitalization: the impact of opioids on pain and healthcare utilization. Dig Dis Sci. 2020;65(6):1777-1783.doi:10.1007/s10620-019-05906-x DOI: https://doi.org/10.1007/s10620-019-05906-x

Järnerot G, Hertervig E, Friis-Liby I, Blomquist L, Karlén P, Grännö C, et al. Infliximab as rescue therapy in severe to moderately severe ulcerative colitis: a randomized, placebo-controlled study. Gastroenterology. 2005;128(7):1805-1811. doi:10.1053/j.gastro.2005.03.003 DOI: https://doi.org/10.1053/j.gastro.2005.03.003

Nalagatla N, Falloon K, Tran G, Borren NZ, Avalos D, Luther J, et al. Effect of accelerated infliximab induction on short- and long-term outcomes of acute severe ulcerative colitis: a retrospective multicenter study and meta-analysis. Clin Gastroenterol Hepatol. 2019;17(3):502-509.e501.doi:10.1016/j.cgh.2018.06.031 DOI: https://doi.org/10.1016/j.cgh.2018.06.031

Lichtiger S, Present DH, Kornbluth A, Gelernt I, Bauer J, Galler G, et al. Cyclosporine in severe ulcerative colitis refractory to steroid therapy. N Engl J Med. 1994;330(26):1841-1845. doi:10.1056/nejm199406303302601 DOI: https://doi.org/10.1056/NEJM199406303302601

Van Assche G, D'Haens G, Noman M, Vermeire S, Hiele M, Asnong K, et al. Randomized, double-blind comparison of 4 mg/kg versus 2 mg/kg intravenous cyclosporine in severe ulcerative colitis. Gastroenterology. 2003;125(4):1025-1031. doi:10.1016/s0016-5085(03)01214-9 DOI: https://doi.org/10.1016/S0016-5085(03)01214-9

Narula N, Marshall JK, Colombel JF, Leontiadis GI, Williams JG, Muqtadir Z, et al. Systematic review and meta-analysis: infliximab or cyclosporine as rescue therapy in patients with severe ulcerative colitis refractory to steroids. Am J Gastroenterol. 2016;111(4):477-491. doi:10.1038/ajg.2016.7 DOI: https://doi.org/10.1038/ajg.2016.7

Eronen H, Oksanen P, Jussila A, Huhtala H, Helavirta I, Ilus T. Long-term outcomes of patients with acute severe ulcerative colitis treated with cyclosporine rescue therapy. Scand J Gastroenterol. 2023;58(5):483-488. doi:10.1080/00365521.2022.2143727 DOI: https://doi.org/10.1080/00365521.2022.2143727

Gisbert JP, García MJ, Chaparro M. Rescue therapies for steroid-refractory acute severe ulcerative colitis: a review. J Crohns Colitis. 2023;17(6):972-994. doi:10.1093/ecco-jcc/jjad004 DOI: https://doi.org/10.1093/ecco-jcc/jjad004

Takahashi T, Shiga H, Tarasawa K, Shimoyama Y, Naito T, Moroi R, et al. Comparative effectiveness of tacrolimus and infliximab in hospitalized patients with ulcerative colitis. Clin Transl Gastroenterol. 2024;15(1):e00642. doi:10.14309/ctg.0000000000000642 DOI: https://doi.org/10.14309/ctg.0000000000000642

Steenholdt C, Dige Ovesen P, Brynskov J, Benedict Seidelin J. Tofacitinib for acute severe ulcerative colitis: a systematic review. J Crohns Colitis. 2023;17(8):1354-1363. doi:10.1093/ecco-jcc/jjad036 DOI: https://doi.org/10.1093/ecco-jcc/jjad036

Berinstein JA, Sheehan JL, Dias M, Bernstein EM, Steiner CA, Johnson LA, et al. Tofacitinib for biologic-experienced hospitalized patients with acute severe ulcerative colitis: a retrospective case-control study. Clin Gastroenterol Hepatol. 2021;19(10):2112-2120.e1. doi:10.1016/j.cgh.2021.05.038 DOI: https://doi.org/10.1016/j.cgh.2021.05.038

Sandborn WJ, D'Haens GR, Sands BE, Panaccione R, Ng SC, Lawendy N, et al. Tofacitinib for the treatment of ulcerative colitis: an integrated summary of up to 7.8 years of safety data from the Global Clinical Programme. J Crohns Colitis. 2023;17(3):338-351. doi:10.1093/ecco-jcc/jjac141 DOI: https://doi.org/10.1093/ecco-jcc/jjac141

Krugliak Cleveland N, Friedberg S, Choi D, Hunold T, Choi NK, Garcia NM, et al. P724 Upadacitinib is effective and safe in tofacitinib-experienced patients with ulcerative colitis: a prospective real-world experience. Journal of Crohn's and Colitis. 2023;17(Supplement_1):i854-i856. doi:10.1093/ecco-jcc/jjac190.0854 DOI: https://doi.org/10.1093/ecco-jcc/jjac190.0854

Zinger CH, Ringel Y, Eitan M, Openhaim M, Kayless H, Stein A, et al. Upadacitinib for acute severe ulcerative colitis. Inflamm Bowel Dis. 2023;29(10):1667-1669. doi:10.1093/ibd/izad180 DOI: https://doi.org/10.1093/ibd/izad180

Ali NM, Shehab MA. Upadacitinib as a rescue therapy in acute severe ulcerative colitis: a case report and review of the literature. Am J Case Rep. 2023;24:e940966. doi:10.12659/ajcr.940966 DOI: https://doi.org/10.12659/AJCR.940966

Gilmore R, Tan WL, Fernandes R, An YK, Begun J. Upadacitinib salvage therapy for infliximab-experienced patients with acute severe ulcerative colitis. J Crohns Colitis. 2023;17(12):2033-2036. doi:10.1093/ecco-jcc/jjad115 DOI: https://doi.org/10.1093/ecco-jcc/jjad115

Lee KE, Sizemore JA, Kim G, Shen B, Sands BE. Impact of biologics and small molecule agents on postoperative complications in inflammatory bowel disease: a systematic review. Dis Colon Rectum. 2024. doi:10.1097/dcr.0000000000003222 DOI: https://doi.org/10.1097/DCR.0000000000003222

Gordon BL, Battat R. Therapeutic drug monitoring of infliximab in acute severe ulcerative colitis. J Clin Med. 2023;12(10). doi:10.3390/jcm12103378 DOI: https://doi.org/10.3390/jcm12103378

Gordon M, Sinopoulou V, Grafton-Clarke C, Akobeng AK. Antibiotics for the induction and maintenance of remission in ulcerative colitis. Cochrane Database Syst Rev. 2022;5(5):Cd013743. doi:10.1002/14651858. CD013743.pub2 DOI: https://doi.org/10.1002/14651858.CD013743.pub2

Downloads

Published

2024-09-11

How to Cite

1.
Klemm N, Leung Y. Acute Severe Ulcerative Colitis: Review of Management and Emerging Treatments. Can IBD Today [Internet]. 2024 Sep. 11 [cited 2024 Oct. 16];2(2):12–17. Available from: https://canadianibdtoday.com/article/view/2-2-Klemm_et_al

Issue

Volume 2, Issue 2, Summer 2024

Section

Articles

License

Copyright (c) 2024 Canadian IBD Today

Creative Commons License

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.