DAY 2 - Improving Outcomes for the Hospitalized IBD Patient: Strategies for Optimizing Inpatient Care

"25% of patients with ulcerative colitis may experience severe disease, and around 40% of these acute severe cases may not respond to steroid treatment," stated Dr. Tauseef Ali, Medical Executive Director of the SSM Health Digestive Institute in Edmond, Oklahoma. Speaking at the American College of Gastroenterology (ACG) 2024 Annual Scientific Meeting in Philadelphia, Dr. Ali outlined his approach to managing hospitalized inflammatory bowel disease (IBD) patients, emphasizing a thorough diagnostic work-up, supportive care, dietary guidance, and symptom management.

Dr. Ali highlighted the traditional Truelove and Witts criteria for defining acute severe ulcerative colitis (ASUC) but acknowledged that some variables in these criteria are subjective. He pointed to emerging non-invasive markers—such as fecal calprotectin and the CRP-albumin ratio—as valuable tools for early diagnosis with high sensitivity and specificity. For the initial workup, he recommended screening for infections like cytomegalovirus and Clostridioides difficile, both linked to steroid resistance and higher colectomy risk. Research suggests that early endoscopic evaluation within 72 hours can reduce the need for intravenous (IV) steroids and lower colectomy rates.

IV steroids have been the cornerstone of ASUC treatment since the 1950s. However, elevated C-reactive protein (CRP) levels, low albumin, increased disease severity, and high intestinal ultrasound scores may lead to steroid failure. Alternative rescue therapies should be considered if a patient does not respond to steroids within seven days. Dr. Ali emphasized the importance of rescue therapies like infliximab and cyclosporine for steroid-resistant patients. 

Clinical trials are needed to develop evidence-based strategies and improve the care of this high-risk patient population. However, Dr. Ali addressed several challenges in conducting clinical trials for ASUC, including a lack of consensus on defining disease severity, limited validation of the Truelove and Witts criteria, difficulty recruiting patients due to the condition’s acute nature, and the absence of standardized outcome measures. Additionally, researchers face obstacles like a lack of effect size estimates for calculating appropriate sample sizes and no consensus on optimal inpatient steroid dosing and tapering regimens. 

Dr. Ali concluded his talk by recommending a comprehensive approach to optimize care for patients with ASUC: early, accurate diagnosis using non-invasive markers; timely and effective medical treatment; careful steroid management; and early implementation of rescue therapies when needed. He also emphasized the importance of managing complications, such as thromboembolism, optimizing nutritional status, and employing a multidisciplinary team approach to improve patient outcomes.