October 29, 2024
"1 in 4 patients with ulcerative colitis (UC) will be admitted to the hospital", Kara M. De Felice, MD, Associate Professor of Medicine at the University of Cincinnati, set the stage at the American College of Gastroenterology (ACG) 2024 Annual Scientific Meeting, held in Philadelphia, Pennsylvania, for her discussion on the appropriate therapy advanced candidates versus surgery for a biologic-experienced patient with UC.
Many patients with UC respond well to initial therapies. Still, a subset develops severe, treatment-refractory diseases requiring more aggressive intervention. This is especially true for those who have previously failed biologics, a group at high risk for poor outcomes. Dr. De Felice highlighted the challenges in managing severe, biologic-experienced UC patients and emphasized the need for a multifaceted, proactive approach to care.
Identifying high-risk predictors such as young age, extensive disease, and early steroid dependence allows clinicians to stratify patients and implement appropriate treatment strategies from the outset. Coordinating inpatient and outpatient care from admission is critical. Patients with a clear post-discharge plan—whether for continued medical therapy or surgical intervention—are more likely to achieve sustained remission than those without a well-defined outpatient strategy.
"We need to be ready and have a protocol in place in our hospitals to manage these patients immune to disease activity as well as disease severity.", noted Dr. De Felice.
At the initial hospitalization stage, Dr. De Felice recommended promptly starting first-line therapies, typically intravenous (IV) corticosteroids. She discussed a structured approach that involves assessing the patient's response within 72 hours to decide on the suitability of steroid monotherapy. For patients at high risk of failing this approach, combining small molecule therapies, such as JAK inhibitors, with high-dose steroids can significantly mitigate disease activity. "JAK inhibitors, when carefully selected and closely monitored, can rapidly reduce disease activity and may eliminate the need for more invasive rescue therapies," she said, underscoring the emerging role of these agents for patients with severe, refractory disease.
When discussing advanced medical therapies, Dr. De Felice highlighted the efficacy of several options depending on the patient's prior exposure to specific biologics or other treatments. For instance, candidates like infliximab, tofacitinib, upadacitinib, or cyclosporine may be selected based on the patient's history of biologics(naive, exposed to adalimumab, golimumab, or JAK inhibitors). Each treatment choice requires careful consideration of the patient's unique history and monitoring potential adverse effects, such as thrombotic events and herpes zoster infection, particularly with JAK inhibitors.
A central theme of Dr. De Felice's presentation was the need for meticulous planning beyond the patient's hospital stay. For those treated with advanced therapies, inpatient-to-outpatient continuity is paramount. She suggested initiating prior authorizations for outpatient medications early, given that insurance coverage often varies significantly between inpatient and outpatient settings. This foresight helps ensure no interruption in therapy post-discharge, which is crucial for maintaining remission.
Cyclosporine, for instance, while beneficial as a rescue therapy, has a narrow therapeutic index and requires a carefully structured transition plan. Patients treated with cyclosporine in the hospital need a clearly defined outpatient regimen, potentially involving biologics or other small molecules, to sustain remission once they are discharged.
Surgical intervention, particularly colectomy, can be lifesaving for patients who do not respond to medical therapies. Dr. De Felice cautioned against delaying surgery unnecessarily, as prolonged reliance on steroids increases the risk of perioperative infections and postoperative complications. Early discussions with patients about surgical options, especially when hospitalization reveals severe inflammation, allow patients to make informed choices about their treatment paths. "Surgery is a valuable option; delaying surgery can come with very effective complications." Dr. De Felice emphasized that collaboration with surgeons experienced in inflammatory bowel disease (IBD) is preferred. The timing and decision to proceed with surgery should be patient-centric, considering the patient's preferences, disease trajectory, and expected quality of life post-surgery. Delaying surgery in the hope of an eventual medical response can lead to adverse outcomes, making timely intervention essential.
To illustrate the importance of cohesive care, Dr. De Felice shared a case study of a patient admitted with acute severe ulcerative colitis (ASUC). In this case, proactive coordination between inpatient and outpatient teams, alongside a comprehensive discharge plan, enabled the patient to achieve and maintain remission without recurrent hospitalizations. Such success underscores the critical role of structured transitions from hospital to home care, ensuring patients have the resources and follow-up support needed for sustained disease control.
Dr. De Felice concluded her presentation with several take-home points, summarizing the key considerations for managing biologic-experienced UC patients effectively:
- Predict the need for rescue therapy early.
- Consider small molecules as first-line therapy in anti-TNF-exposed patients.
- Plan post-hospital discharge maintenance therapy alongside inpatient decisions.
- Surgery is often beneficial; involve surgical teams early.
- Delaying surgery increases risks associated with poor outcomes due to steroids and other factors.