ABSTRACT
BACKGROUND: Acute severe ulcerative colitis (ASUC) is a complication of ulcerative colitis associated with high levels of circulating tumor necrosis factor alpha, due to the intense inflammation and faster stool clearance of anti-tumor necrosis factor drugs. Dose-intensified infliximab treatment can be beneficial and is associated with lower rates of colectomy. The aim of the study was to present a case of a patient with ASUC and megacolon, treated with hydrocortisone and accelerated scheme of infliximab that was monitored by drug trough level. CASE SUMMARY: A 22-year-old female patient diagnosed with ulcerative colitis, presented with diarrhea, rectal bleeding, abdominal pain, vomiting, and distended abdomen. During investigation, a positive toxin for Clostridium difficile and colonic dilatation of 7 cm consistent with megacolon were observed. She was treated with oral vancomycin for pseudomembranous colitis and intravenous hydrocortisone for severe colitis, which led to the resolution of megacolon. Due to the persistent severe colitis symptoms, infliximab 5 mg/kg was prescribed, monitored by drug trough level (8.8 µg/mL) and fecal calprotectin of 921 µg/g (< 30 µg/g). Based on the low infliximab trough level after one week from the first infliximab dose, the patient received a second infusion at week 1, consistent with the accelerated regimen (infusions at weeks 0, 1, 2 and 6). We achieved a positive clinical and endoscopic response after 6 mo of therapy, without the need for a colectomy. CONCLUSION: Infliximab accelerated infusions can be beneficial in ASUC unresponsive to the treatment with intravenous corticosteroids. Longitudinal studies are necessary to define the best therapeutic drug monitoring and treatment regimen for these patients.
ABSTRACT
Introduction: Despite the introduction of novel therapies and treatment strategies for ulcerative colitis (UC), many patients develop acute, severe episodes, warranting prompt care and aggressive management. There is a significant unmet need to improve outcomes in these patients. Clinicians must be able to identify those that will have worse prognosis and plan an aggressive therapy with an early/proactive adjustments in management if needed.Areas covered: The aim of this review is to evaluate the most recent evidence on the assessment and management of patients with acute severe ulcerative colitis. We searched the mainstream literature search engines for the most recent evidence on diagnosis and management of acute UC.Expert Opinion: The approach to patients with severe UC includes clinical and endoscopic assessment of disease severity and ruling out over-infections. While intravenous corticosteroids remain the first line therapy for acute severe colitis, many patients do not respond and require escalation to calcineurin inhibitors or infliximab, and may ultimately require colectomy. Even though several novel therapies are available or in development, their role in acute severe episodes of colitis is unknown.
Subject(s)
Anti-Inflammatory Agents/therapeutic use , Biological Products/therapeutic use , Colitis, Ulcerative/drug therapy , Gastrointestinal Agents/therapeutic use , Acute Disease , Anti-Inflammatory Agents/adverse effects , Biological Products/adverse effects , Colectomy , Colitis, Ulcerative/diagnosis , Disease Progression , Gastrointestinal Agents/adverse effects , Humans , Remission Induction , Risk Factors , Severity of Illness Index , Treatment OutcomeABSTRACT
La colitis ulcerativa aguda severa es una urgencia médica que puede comprometer la vida del paciente; requiere una alta sospecha diagnóstica para establecer un manejo adecuado y oportuno, y prevenir complicaciones. Es necesario determinar factores pronósticos para identificar pacientes de alto riesgo. Los esteroides intravenosos son tratamiento de primera línea, en caso de no respuesta, el uso de terapia de "rescate" con infliximab o ciclosporina reduce el riesgo de colectomía a corto plazo, sin comprometer la seguridad del paciente.
Acute severe ulcerative colitis is a potentially life-threatening condition that requires a pro-active approach with either effective medical treatment or timely colectomy. It is very important to identify at an early stage those who are likely to fail intensive treatment. Although intravenous steroids remain the first line, for those who fail, currently available 'rescue' medical therapy with infliximab and cyclosporine may reduce the risk of colectomy in the short term without compromising safety.