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Evidence-based guidelines for ulcerative colitis management
Anne Griffiths MD, FRCPC
SickKids Hospital, University of Toronto
Buenos Aires, August 14, 2014
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Dan Turner, Jerusalem
Consensus guidelines for managing acute severe ulcerative colitis in childrenA joint statement from ECCO, ESPGHAN, and the Porto IBD Working Group of ESPGHAN
Turner D, Travis SP, Griffiths AM, et al. Am J Gastro 2011: 141: 1566-1571
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Dan Turner, Jerusalem
Management of pediatric ulcerative colitis Joint ESPGHAN and ECCO evidence-based consensus guidelines
Turner D, Levine A, Griffiths AM et al. J Pediatr Gastro Nutr 2012: 55: 340-361
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OUTLINE
Making the right diagnosis: is it ulcerative colitis
Assessing disease activity
Optimizing medical treatment of UC– Acute severe UC– Mild to moderately severe UC
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OUTLINE
Making the right diagnosis: is it ulcerative colitis?
Assessing disease activity
Optimizing medical treatment of active UC
Optimizing maintenance therapy
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Inflammatory bowel disease
Ulcerative Colitis Crohn Diseases
ClinicalPhenotypes
A SPECTRUM of related disordersLabeling less important than anticipated treatment responsiveness
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Controversial issues in classification of colonic IBD Rectal sparing
– May be relative rectal sparing in UC– Normal rectal histology = CD
Histologic gastritis– Non-specific gastritis common in UC– Only antral granulomata diagnostic of CD
Histologic ileitis– In severe pancolitis, ileal inflammation may be observed
(histologically focal acute)
Paediatric working group reportBousvaros A et al; J Pediatr Gastro Nutr 2007; 44: 653-674
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How consistently do paediatric IBD experts apply “Labels” of CD/UC/IBD-U?
Type of IBD # Cases Kappa (95% confidence interval)
CD, UC or IBDU
50 (all study cases) 0.60 (0.58-0.63)
Inter-relater reliability
Sherlock M et al, CCFA conference 2010Sherlock M et al, CCFA conference 2010
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Making the right diagnosis: Potential consequences of “mis-labeling”
5-ASA, which when optimized is effective maintenance therapy in “UC” is not given (because of CD label)
Methotrexate maintenance therapy is prescribed for a patient, who truly has “UC” (because of CD label)
“Curative” colectomy is deferred for too long in a “UC” patient with chronic steroid dependency and consequent growth impairment (because of CD label)
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OUTLINE
Making the right diagnosis: is it ulcerative colitis
Assessing disease activity
Optimizing medical treatment of active UC
Optimizing maintenance therapy
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Assessing activity in UC
Usually easier than in Crohn’s disease
Sequence of increasing activity….blood in loose stools…..blood in more loose stools…more blood in more loose stools….lots of blood in lots of loose stools and pain
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Pediatric UC Activity Index (PUCAI)
ITEM POINTS
1. Abdominal pain No pain Pain can be ignored Pain cannot be ignored
0 5 10
2. Rectal bleeding None Small amount only in < 50% of stools Small amount with most stools Large amount (>50% of the stool content)
0 10 20 30
3. Stool consistency of most stools Formed Partially formed Completely unformed
0 5 10
4. Number of stools per 24 hours 0-2 3-5 6-8 >8
0 5 10 15
5. Nocturnal bowel movement (any diarrhea episode causing wakening)
No Yes
0 10
6. Activity level No limitation of activity Occasional limitation of activity Severe restricted activity
0 5 10
SUM OF PUCAI (0-85)
Remission: <10Mild: 10-30Moderate: 35-60Severe: 65-85
Turner D et al; Gastroenterology 2007;133:423-432
Validation in adults: Turner D, Seow C et al: Clin Gastro Hepatol 2009; 7: 1081-1088
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Recognize acute severe ulcerative colitis!
• Frequent bloody diarrhea, nocturnal stools, abdominal pain ++
• An IBD emergency
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Select initial treatment according to disease activity
Hospitalized Acute Severe
Non Hospitalized Moderate to Severe
Non Hospitalized Mild 30%
35%
20%
15%
5-ASA
Out-patient steroids
Intravenous steroids
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Induction therapy is chosen with maintenance strategy in mind
– 5-ASA…………5-ASA maintenance
– Steroids………5-ASA maintenance ….?or thiopurine maintenance
– Anti-TNF…… scheduled anti-TNF maintenance ? + concomitant immunemodulator
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OUTLINE
Making the right diagnosis: is it ulcerative colitis
Assessing disease activity
Optimizing medical treatment of active UC– Acute severe UC– Mild to moderately severe UC
Optimizing maintenance therapy
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Dan Turner, Jerusalem
Consensus guidelines for managing acute severe ulcerative colitis in childrenA joint statement from ECCO, ESPGHAN, and the Porto IBD Working Group of ESPGHAN
Turner D, Travis SP, Griffiths AM, et al. Am J Gastro 2011: 141: 1566-1571
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Corticosteroid dosing in acute severe UC
Practice pointsa. Methylprednisolone is preferred over
hydrocortisone because it has fewer mineralocorticoid effects.
Intravenous methylprednisolone, 1 to 1.5 mg/kg/day, is recommended to a maximum of 60 mg given in one or two divided daily doses [EL2, RG B]
Am J Gastroenterol 2011; 141: 1566-1571
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Avoid prolonged IV corticosteroid therapy if ineffective
Recognize early the patient who will not respond to IV steroids
Prepare to introduce second line therapy in timely fashion
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Short term steroid failure rate in childrenThe OSCI multi-centre study
0
10
20
3029%
37/128
Turner D et al, Gastroenterology 2010; 138: 2282 -2291
2006-2008
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“Get set….go” Criteria: Day 3
Turner D et al. Am J Gastroenterol 2011
Daily PUCAI assessment to day 5
PUCAI>45 PUCAI 35-45 PUCAI<35
-Screen for 2nd line therapy-Consult surgeons -Consult stoma therapist-Repeat blood tests
Sigmoidoscopy
Consider switching to oral prednisone and discharge
PPV=43% NPV=95% NPV=98%
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“Get set….go” Criteria: Day 5
Turner D et al. Am J Gastroenterol 2011
- Repeat blood tests- Daily PUCAI assessment
PUCAI>65 PUCAI 40-65 PUCAI<35
Start second line medical therapy
Consider switching to oral prednisone and discharge
PUCAI>65: PPV=82%PUCAI>70: PPV=87-100% NPV ~80%
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Treatment of steroid-refractory UC
• Infliximab: preferred in most centers because of better toxicity profile + ability to continue as maintenance therapy
• Calcineurin inhibitors
• Colectomy
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Management of ulcerative colitis: ECCO/ESPGHAN guidelines
• Infliximab is indicated in steroid refractory disease Turner D et al, JPGN 2012
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OUTLINE
Making the right diagnosis: is it ulcerative colitis
Assessing disease activity
Optimizing medical treatment of UC– Acute severe UC– Mild to moderately severe UC
Optimizing maintenance therapy
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Management of ulcerative colitis: ECCO/ESPGHAN guidelines
High dose oral 5-ASA is the first line therapy for both induction and maintenance of remission in children without acute severe colitis
Turner D et al, JPGN 2014
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Remission and improvement rates.
Marteau P et al. Gut 2005;54:960-965
Combined oral and enema 5-ASA vs oral 5-ASA alone in extensive mild-moderate UC
64%
43%
P=.03
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Predicting Response tOSTandardized PEdiatric Colitis Therapy
1U01 DK 095745-01
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Aims of PROTECT
Define rates of week 52 steroid free remission with 5-ASA as sole maintenance therapy in patients receiving standardized induction therapy with 5-ASA/corticosteroids
Test predictors of week 52 Steroid Free Remission
Identify biologic pathways associated with initial response and week 52 Steroid Free Remission
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Initial Therapy By Disease Activity Assessment (PUCAI)
Baseline PUCAI Pentasa Oral Steroids
IV Steroids
Mild (n=67) 58 (86.6%) 6 (9.0%) 2 (3.0%)
Moderate (n=123) 39 (31.7%) 60 (48.8%) 22 (17.9%)
Severe (n=82) 2 (2.4%) 22 (26.8%) 57 (69.5%)
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5-aminosalicylic acid
Dosing in children with ulcerative colitis– 50 - 75 mg/kg/day in NIH-funded PROTECT study in new
onset pediatric UC
31
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Management of ulcerative colitis: ECCO/ESPGHAN guidelines
Thiopurines are recommended for maintaining remission in children with: frequent relapses (2-3 relapses per year); steroid-dependent disease, despite the use of maximal 5-ASA treatment ; after most acute severe colitis cases
Turner D et al, JPGN 2012
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Does adding 5-ASA to azathioprine improve outcomes in UC?
No difference:– Time to relapse– Discontinuation of
treatment– UCDAI score– IBDQ score
Combination therapy:– More adverse events*– Increased costs– Reduced compliance *pain, diarrhea, transient leukopenia, infection
Mantzaris GJ. Am J Gastroenterol 2004;99:1122-8
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Azathioprine metabolism and 5-ASA
Dubinsky MC. Gastroenterology 2002;122:904-15
5-ASAInhibitsTPMT
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Management of ulcerative colitis: ECCO/ESPGHAN guidelines
• Infliximab should be considered for treatment of children with persistently active, or steroid-dependent UC when maintenance of steroid-free remission is not achieved by 5-ASA and thiopurines
Turner D et al, JPGN 2012
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Moderate UC Algorithm:Accelerated Step Care
Moderate
Prednisone
UC SUCCESS
16‒24 weeks
Steroid dependent
AZA x 12‒16 weeks
IFX 0, 2, 6+/-
Immunomodulators
First or second flare-up
Adapted from: Panaccione R, et al. Aliment Pharmacol Ther. 2008;28:674-688.
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LOR > 8WkInfliximab
5 mg/kg q8w(n=6)
Infliximab 5 mg/kg***
Infliximab in ambulatory pediatric patients with UC: Study Design
Week 0
Week 2
Week 6
All sujects (n=60)
Week 8
Week 14
Week 22
Week 30
Responders (n=45)
Non-respondersNo further infliximab
(n=15)
Infliximab 5 mg/kg q8w (n=22)
Infliximab 5 mg/kg q12w (n=23)
Week 30
Week 18
Evaluation at week 54
Week 38
Week 46Week 42
Visits
*****
*
*
**InfusionsLOR = loss of response
LORInfliximab
10 mg/kg q8w(n=6)
LOR ≤ 8WkInfliximab
10 mg/kg q8w(n=8)
PedUC
Hyams et al., DDW2011. Abstract 747
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Response, Remission and Mucosal Healing at Week 8
40.0%
33.3%
68.3%
73.3%
0%
20%
40%
60%
80%
100%
Response Remission(Mayo)
Remission(PUCAI)
Mucosalhealing
Percen
t of pa
tients
PedUC
44/60 24/60 17/51 41/60
: Criterion for positive response
(95% C.I.: 62.1%-84.5%)
Hyams et al Clin Gastro Hepatol 2012; 10: 391-399.
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IFX+Azathioprine in Ambulatory UC
n=18 n=17 n=31
p=0.813
p=0.032
p=0.017
Steroid-Free Remission† at Week 16Primary endpoint
†Total Mayo score ≤ 2, with no individual subscore > 1, and no steroids
UC-SUCCESS
Panaccione et al. Gastroenterology 2013
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Clinical outcomes according to antibody to infliximab status.
Seow C H et al. Gut 2010;59:49-54
TROUGH LEVELS PREDICTCLINICAL OUTCOME
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Summary: important take-home messages
Diagnose UC appropriately
Assess disease activity accurately
Optimized 5-ASA is effective maintenance therapy
Thiopurines or infliximab or combination in UC which is steroid dependent despite optimized 5-ASA
Infliximab for steroid-refractory UC
Therapeutic drug monitoring with biologics is important
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