Predictors of Colectomy at 1 Year in Severe Ulcerative Colitis

Predictors of Colectomy at 1 Year in Severe Ulcerative Colitis

Monika Fischer, MD, reviewing Le Baut G, et al. Clin Gastroenterol Hepatol 2020 Jan 9.

A French IBD consortium studied 270 hospitalized patients with severe ulcerative colitis (UC) for a median follow-up of 30 months. They developed an externally validated scoring system for prediction of colectomy within 1 year of hospitalization. They found that 4 factors were independently associated with this outcome: C. difficile infection, C-reactive protein serum level >30 mg/L, serum albumin concentration <3 g/dL, and previous exposure to an anti-tumor necrosis factor (TNF) or thiopurine analog. For the risk score, each factor was given 1 point. Patients who had 4 points had a 100% chance of losing their colon within 1 year, whereas patients with 0 points had a 0% chance of undergoing a colectomy. Patients with 1 or 2 points had a 10% chance, and patients with 3 points had a 50% chance of colectomy. Negative predictive value of the model ranged from 87% to 92%.

COMMENT
This is a very simple and user-friendly risk score that we can all remember when treating hospitalized patients with severe acute UC flare. It is a helpful tool for the physician when deciding between escalated (infliximab, 10 mg/kg x 2) versus standard dosing (infliximab, 5 mg/kg x 1) of an anti-TNF and intensity of postdischarge monitoring. It can also inform shared decision making with patients and families regarding the likelihood of successful outcome on medical therapy alone. 

Despite the early enthusiasm of escalated, high-dose inpatient infliximab therapy, accumulating evidence now suggests that it reduces the risk for 30-day colectomy, but it may not affect the 1-year colectomy rate after all. For example, a patient with 4 points (all 4 predictors of a poor outcome) would likely fare better proceeding with elective colectomy soon after stabilization rather than with continued struggle of poorly controlled disease and exposure to immunosuppression therapy before undergoing unavoidable colectomy.

Monika Fischer, MD, FASGE

CITATION(S )

Le Baut G, Kirchgesner J, Amiot A, et al. A scoring system to determine patients’ risk of colectomy within 1 y after hospital admission for acute severe ulcerative colitis. Clin Gastroenterol Hepatol 2020 Jan 9. (Epub ahead of print) (https://doi.org/10.1016/j.cgh.2019.12.036)

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