Anti-Tumor Necrosis Factor Should Be Considered for Ulcerative Proctitis Refractory to Conventional Therapy
Monika Fischer, MD, reviewing Pineton de Chambrun G, et al. Clin Gastroenterol Hepatol 2020 Mar.
Treatment of ulcerative proctitis that is unresponsive to mesalamine and corticosteroids is challenging. Patients with ulcerative proctitis are generally excluded from clinical trials, hence the lack of data on the role of anti-tumor necrosis factor (TNF) agents in limited distal disease. Previously, azathioprine and topical rectal tacrolimus were shown to be superior compared to mesalamine and placebo. Appendectomy was also recommended as salvage therapy.
In this retrospective cohort from France, 104 patients with refractory ulcerative proctitis received anti-TNF therapy with either infliximab, adalimumab, or golimumab. Fifty percent of the patients achieved clinical remission, while 60% had mucosal healing. At 2 years, 64% of the patients were still receiving an anti-TNF agent. Only 4% of patients required colectomy during the 2-year follow-up. Patients who responded to the first anti-TNF, irrespective of the type, had a 90% probability of being in remission at 1 year, 78% probability at 2 years, and 56% probability at 5 years. Patients who did not respond to the first anti-TNF had a 22% chance of responding to the second anti-TNF and an 80% chance of responding to vedolizumab.
COMMENT
Proctitis causes bleeding, tenesmus, urgency, incontinence, and pain, all of which greatly diminish patients’ quality of life. Despite this, physicians are often hesitant to recommend a biologic agent for the treatment of ulcerative proctitis. The risk-to-benefit ratio of an anti-TNF agent may be perceived as unfavorable in such limited disease. This cohort study presents evidence on the usefulness of anti-TNF agents and, by proxy, vedolizumab in ulcerative proctitis. These treatment modalities should be considered after failure of oral or topical mesalamine and/or corticosteroids, as well as in cases where azathioprine is contraindicated.
Monika Fischer, MD, FASGE
CITATION(S )
Pineton de Chambrun G, Amiot A, Bouguen G, et al. Efficacy of tumor necrosis factor antagonist treatment in patients with refractory ulcerative proctitis. Clin Gastroenterol Hepatol 2020;18:620-627.e1. (https://doi.org/10.1016/j.cgh.2019.05.060)
