Until the advent of corticosteroids and colectomy, nearly a third of inpatients with ulcerative colitis died of their disease. Even with effective treatments available, challenges remain in the medical and surgical management of these patients.
“Severe ulcerative colitis in inpatients is much more severe than anything you see in the outpatient population, [and] maybe not even be the same disease,” said Gert Van Assche, MD, PhD, head of gastroenterology and hepatology at University Hospitals in Leuven, Belgium. “With the medical and surgical treatments we have today, the mortality rate for these patients should be close to zero, but it’s not. They are not getting the intensive care and rigorous follow up they need.”
On Monday, Dr. Van Assche will co-moderate the annual Kiron and Kamala Das Symposium with Sarah Sheibani, MD, assistant professor of clinical medicine at the Keck School of Medicine at the University of Southern California, Los Angeles. The AGA Clinical Symposium is titled Managing the Inpatient with Severe Ulcerative Colitis: A Case-Based, Medical-Surgical Approach.
The standard medical therapy for severe ulcerative colitis is an anti-TNF agent, most commonly infliximab, Dr. Van Assche said. Some centers still rely on cyclosporine or other immunosuppressive agents, but infliximab has emerged as the most effective agent for severe inpatient ulcerative colitis.
“We have tried anti-CD3 agents and other immunotherapies, but they have grossly failed in making these patients better,” Dr. Van Assche said. “We are stuck working with the anti-TNF agents that we have been using for 20 years. The good side is that we are still seeing a lot of spectacular responses.”
There are several new agents in clinical trials for moderate to severe outpatient disease, but no new treatments are in the pipeline for inpatients. The one treatment wrinkle, Dr. Van Assche said, is uncontrolled data suggesting that high-dose infliximab may provide short-term benefits and allow patients to delay colectomy.
“Cyclosporine is generally not a preferred agent if anti-TNF therapy is available,” he said. “Cyclosporine is not appropriate for maintenance, while infliximab can be used successfully long term. The risk of opportunistic infection is also higher with cyclosporine than with infliximab.”
The common problem when treating severe inpatient disease is a delay moving from failed medical therapy to colectomy, Dr. Van Assche said. Once medical treatment fails, colectomy is the only alternative.
“What we see all over the world and most clearly in the latest British data is that there is an unacceptable mortality in these patients because colectomy is being delayed,” Dr. Van Assche said. “We have had successful treatments available since the 1990s, but the message has not gotten to every hospital. Success depends on giving these patients intensive care, making treatment decisions early, starting with the right agents at the right dose and the right time, and then moving to colectomy whenever it is necessary without delay.”
Please refer to the DDW Mobile App or the Program section in Monday’s DDW Daily News for additional details on this and other DDW® events.
Kamala and Kiron Das, MD, PhD, AGAF
Why is the clinical symposium important?
Dr. Das: We are excited to have the opportunity to support and to create a forum where scientists, translational researchers, clinical epidemiologists and master clinicians can share their ideas and cutting-edge insights on IBD. We have tried to craft symposia over the last few years that engage and excite, and apply to a broad range of physicians and scientists in gastroenterology.
What does it mean for you to support the AGA Research Foundation through a clinical symposium?
Dr. Das: I have dedicated my professional career to the care and research of patients with ulcerative colitis and Crohn’s disease, and we are so happy to have the ability to support the AGA and its important missions in research and education.
AGA is grateful to its donors for their generous contributions, which go directly to the AGA Research Foundation awards program endowment to support future research in the field.”