Predictors Of Clinical Response To Systemic Steroids And Rescue Therapy In Patients With Severe Ulcerative Colitis

Aims： To analysis the clinical symptoms, laboratory findings, endoscopicmorphological features and therapeutic effect of severe ulcerative colitis, try to find thepossible early predictors of clinical response to systemic steroids in patients with severeulcerative colitis, and to provide clinical data of rescue therapy in severe ulcerativecolitis patients.Methods： According to the consensus on diagnosis and management of inflammatorybowel disease, medical records of234ulcerative colitis in-patients, including113severe ulcerative colitis patients and121mild ulcerative colitis patients from January2001to February2013in The First Affiliated Hospital of An Hui Medical Universitywere collected. The general data, clinical symptoms at day1~3, laboratory findings andendoscopic morphological features in admission were collected. According to thereaction to glucocorticoids treatment (equivalent of prednisone,1mg/kg/d), severeulcerative colitis patients were divided into complete remission group, partial remissiongroup and non-response group at day7. The ulcerative colitis extent, clinical symptoms,laboratory findings, endoscopic morphological features and treatment outcome of thesethree groups were compared, aim to finding the possible early predictors of clinicalresponse to systemic steroids in patients with severe ulcerative colitis. And in thetreatment of30days and one year follow-up, medium-term and long-term effect ofglucocorticoid treatment were evaluated. Part of partial response and non-responsepatients at short-term glucocorticoid treatment choose to extend the time of glucocorticoid therapy, or choose the rescue therapy such as immunosuppressant,biological agents, or colectomy. Intravenous cyclosporine treatment was administeredwith a dose of2~4mg/kg/d in rescue therapy. Patients who improved were shifted tooral cyclosporine. Infliximab was administered in the dose of5mg/kg/d at0,2, and6weeks and maintenance therapy every8weeks, and monitoring the adverse reactions.Record the treatment condition and outcome of rescue therapy.Results:1. Compared with mild ulcerative colitis patients group, the hospitalizationtime extended obviously in severe ulcerative colitis patients group, the proportion ofmoderate to severe abdominal pain, extensive colitis, initial onset was higher in severeulcerative colitis group, the level of C-reactive protein, erythrocyte sedimentation rate,platelet count, serum albumin level were found with statistical significant differencebetween the two groups (P <0.001). The presence of endoscopic extensive deep ulcerswere found with high frequency, with statistical significant difference (P <0.05).2. Totally113severe ulcerative colitis patients were enrolled, of which85%(96/113) patients received glucocorticoids treatment. Assess the therapeutic effect ofglucocorticoids treatment at day7, complete remission group, partial remission groupand non-response group took up32.3%,26.0%,41.7%respectively. Compared withcomplete remission group, the proportion of partial remission group was higher in stoolfrequency≥10/day on admission, previous severe attack, blood in stools at day3, withstatistical significant difference(P <0.05). The proportion of non-response group washigher in stool frequency≥10/day on admission, previous severe attack, stoolfrequency>6/day at day3, blood in stools at day3, hypoproteinemia and the number ofstool frequency at day1~3, with statistical significant difference(P <0.05). In addition,compared with complete remission group, severe lesions were found with highfrequency in the partial remission group and non-response group, especially punchedout ulcer, with statistical significant difference(P=0.044). 3. At day7of systemic steroids treatment,31(32.3%) patients achievedcomplete remission as previously defined, the percentage increase to42.7%at day30through extending period of glucocorticoids treatment, the percentage of responser was40.6%within1year after hormone therapy, the percentage of glucocorticoidsdependent was29.2%.4.14(14.6%) patients choose rescue therapy or surgical treatment within day7,23(24.0%) patients within one month and27(28.1%) patients within one year choosesecond-line treatment or surgery, an overall colectomy rate was13.5%within1year.6patients using intravenous cyclosporine,4cases response to the therapy, with3casesmaintaining complete remission at one year follow-up,8patients using infliximab,4cases response to the therapy, with4cases maintaining complete remission at one yearfollow-up.Conclusions: Compared with mild ulcerative colitis patients group, the proportion ofmoderate to severe abdominal pain, extensive colitis, and the concentration ofC-reactive protein, increased erythrocyte sedimentation rate, high platelet count,hypoproteinemia were prominent features in severe ulcerative colitis group. In our study,stool frequency≥10/day on admission, previous severe attack, stool frequency>6/dayat day3, blood in stools at day3, hypoproteinemia(<25g/l) and presence of endoscopicextensive deep ulcers which may indicate relatively poor response to systemic steroidsin patients with severe ulcerative colitis. Part of severe ulcerative colitis patients mayachieve partial remission in the glucocorticoids treatment, the percentage of completeremission can be increased by extending the period of steroids therapy, but the risk ofrescue therapies and surgical treatment also increased. Rapid response toglucocorticoids treatment can be predicted by combing clinical symptoms, laboratoryfindings and endoscopic morphological parameters, immunomodulators, biologicalagents and surgery are the further treatment for poor response patients.