Saito et al. present a retrospective study conducted at a single tertiary referral centre over a period of 75 months with the aim of identifying predictive factors of response to intravenous ciclosporin in the setting of acute, severe ulcerative colitis (UC). An acute, severe attack of UC will affect 25% of patients at some point during their disease course, and 20% of first attacks of UC are ‘acute severe’ in nature.
Patients presenting with acute severe UC failing to respond to intravenous corticosteroids at day 3–5 should be considered for rescue medical therapy with either ciclosporin or infliximab, with the aim of avoiding colectomy. Although there are predictive indices of response to corticosteroids,[4-6] predictive factors of response to ciclosporin are less well established.[7-10]
The study included 52 patients and stepwise multiple logistic analysis identified 4 predictive factors of response to intravenous ciclosporin; age at hospitalisation, difference in total protein between days 1 and 3, platelet count on day 1, and Lichtiger score on day 3. The former two parameters have been identified as predictive factors by previous studies.[6, 8, 9] The authors use these factors to propose a novel calculation formula and a decision tree analysis, which predicts colectomy with an accuracy of 90.4%, positive predictive value of 72.2% and negative predictive value of 100%.
Most patients included in the study had disease refractory to other agents including one patient previously treated with tacrolimus and two patients having received infliximab induction therapy. These treatments were stopped 4 weeks prior to ciclosporin administration. A further cohort of 29 patients had received 2–10 sessions of leucocytapheresis, which was discontinued 2–14 days before treatment with ciclosporin. Additionally, a significant proportion of patients had co-existing infection with 19 patients (36.5%) being diagnosed with cytomegalovirus reactivation and four patients (7.7%) found to have clostridial infection after starting ciclosporin.
Allowing for these factors, the study outcomes and proposed calculation formula and decision tree are interesting, and may prove useful in earlier and accurate clinical decision-making in the treatment of steroid-refractory acute severe UC.