See “Does Infliximab Prevent Colectomy in Acute and Chronic Active Ulcerative Colitis?” by Dan-Nielsen et al on page 768.
Ulcerative colitis (UC) is a chronic inflammatory bowel disease that can affect both children and adults. Goals of treatment are induction and maintenance of remission to preserve the colon and its functions while minimizing the risks of treatment morbidities. Nevertheless, sometimes colectomy remains the only treatment option, especially in acute attacks. In the first 60 years of the last century, the majority of patients underwent colectomy. The introduction of corticosteroids in the 1960s reduced the colectomy rate by 60%, and recently, the use of cyclosporine reduced it by 80% (1). Recently, it has been demonstrated that infliximab (IFX) is an effective treatment for moderate-to-severe UC, including acute severe colitis. The ACT 1 and ACT 2 randomized trials conducted in adult UC patients (2) showed a colectomy rate of 10% in the IFX-treated arm, versus 17% in the placebo arm. A paediatric multicentre study by Turner et al (3) showed that IFX is effective as salvage medical therapy in 70% to 80% of affected children, reducing short- and long-term colectomy rate. Consequently, IFX has been used as a possible last treatment option, before colectomy in adult and children and has been recommended as rescue therapy for paediatric patients, failing intravenous corticosteroids before colectomy (4).
The study of Nielsen et al (5) in this issue of the Journal of Pediatric Gastroenterology and Nutrition is a long-term retrospective multicentre paediatric study on a relatively large cohort of children, with chronic active or acute UC treated with IFX. Primary endpoints of the study were clinical response, risk of surgery, risk of new course of steroids, and safety in IFX treatment. It shows a total response rate (full or partial remission) in 69% of patients and 1 year and 2 year cumulative risk of colectomy, after IFX treatment of 21% and 26%, respectively, with no difference between patients in full or partial remission. It showed a lower risk of colectomy compared with a recent study by Hyams et al (6) in which the 1- and 2-year colectomy rate was 28% and 39%, respectively. It also demonstrated a lower need of subsequent use of corticosteroids after starting IFX, as compared with the Hyams et al (6) study. Adverse effects were reported in 46% of patients, but only 7% discontinuation of the therapy was required; this is in line with previous reports.
Despite the limitation of being a retrospective design with heterogeneous population, this study confirms that IFX is a viable and safe treatment in both chronic active and acute UC in children before considering colectomy. Colectomy is a lifesaving procedure in patients with toxic megacolon or acute surgical abdomen but can lead to serious chronic complications such as pouchitis, faecal incontinence, anastomotic ulcers and stenosis, and female infertility. Therefore, IFX treatment should always be considered before colectomy. Further studies are needed with larger and more homogenous populations, and with a longer follow-up, to establish the efficacy and safety of the treatment in the long term.
1. Castro M, Papadatou B, Ceriati E, et al. Role of cyclosporin in preventing or delaying colectomy in children with severe ulcerative colitis. Langenbecks Arch Surg
2. Sandborn WJ, Rutgeerts P, Feagan BG, et al. Colectomy rate comparison after treatment of ulcerative colitis with placebo or infliximab. Gastroenterology
3. Turner D, Mack D, Leleiko N, et al. Severe pediatric ulcerative colitis: a prospective multicenter study of outcomes and predictors of response. Gastroenterology
4. Turner D, Travis SP, Griffiths AM, et al. Consensus for managing acute severe ulcerative colitis in children: a systematic review and joint statement from ECCO, ESPGHAN, and the Porto IBD Working Group of ESPGHAN. Am J Gastroenterol
5. Dan-Nielsen S, Wewer V, Paerregaard A, et al. Does infliximab prevent colectomy in acute and chronic active ulcerative colitis? J Pediatr Gastroenterol Nutr
6. Hyams J, Walters TD, Crandall W, et al. Outcome following infliximab therapy in children with ulcerative colitis. Am J Gastroenterol