In-hospital management of inflammatory bowel disease

Abstract

Purpose of review: The management of hospitalized patients with inflammatory bowel disease (IBD) is complex. Despite considerable therapeutic advancements in outpatient ulcerative colitis and Crohn's disease management, the in-hospital management continues to lag with suboptimal outcomes. The purpose of this review is to provide a brief overview of our approach to managing patients hospitalized with acute severe ulcerative colitis (ASUC) and Crohn's disease-related complications, followed by a summary of emerging evidence for new management approaches.

Recent findings: ASUC has seen the emergence of well validated prognostic models for colectomy as well as the development of novel treatment strategies such as accelerated infliximab dosing, Janus kinase inhibitor therapy, and sequential therapy, yet the rate of colectomy for steroid-refractory ASUC has not meaningfully improved. Crohn's disease has seen the development of better diagnostic tools, early Crohn's disease-related complication stratification and identification, as well as better surgical techniques, yet the rates of hospitalization and development of Crohn's disease-related complications remain high.

Summary: Significant progress has been made in the in-hospital IBD management; however, both the management of ASUC and hospitalized Crohn's disease remain a challenge with suboptimal outcomes. Critical knowledge gaps still exist, and dedicated studies in hospitalized patients with IBD are needed to address them.

Figure 1:. Treatment Effectiveness Window for Acute Severe Ulcerative Colitis.

If appropriate early medical management is provided while a patient is within their treatment effectiveness window, a patient is more likely to experience improvement in their inflammatory biomarkers and symptoms allowing them to be discharged from the hospital and subsequently experience mucosal healing.

Figure 2:. Rate of Colectomy Over Time Among Acute Severe Ulcerative Colitis Patients who Initially Responded to Cyclosporine.

Please note that patients were maintained on azathioprine monotherapy (37% were on azathioprine prior to cyclosporine initiation and 63% were started on azathioprine after cyclosporine initiation). No patients were maintained on biologics as study took place between 1992 and 2004. This study was conducted at a single tertiary care center in Leuven Belgium. Adapted from Moskovitz et al. CGH 2006.(38)

Figure 3:. Long-term CySIF Trial Outcomes of Patients with Steroid-refractory Acute Severe Ulcerative Colitis Treated with Cyclosporine or Infliximab.

There was no significant difference in the colectomy-free survival at 90-days, 1 year, and 5 years. Please note that by 5 years, 62% of patients who received cyclosporine were on a new systemic therapy (mostly infliximab) compared to only 22% in the infliximab treatment arm. Adapted from Laharie D et al. Gut. 2018.(59)

Figure 4:. Trends in Mortality and Colectomy Over Time.

Mortality in the pre-steroid era was observed to be as high as 75% in the year following an episode of ASUC. Fortunately, ASUC mortality improved to < 1% after the introduction of corticosteroids and early colectomy, yet the rate of colectomy has only marginally improved despite the application of infliximab and cyclosporine rescue therapy. Adapted from Viscido A et al. Biologics 2019.(87)