Predictors of response to steroid therapy in patients with acute, severe ulcerative colitis

To the Editor, We have read with great interest the paper by Han et al. [1] about the early predictors of responses of corticosteroid treatment for severe ulcerative colitis (UC). We absolutely agree that identifying factors that may predispose the outcome of intensive steroid and rescue therapies or may even be able to assess the risk of colectomy in acute, severe UC is crucially important. On that occasion, this was not the first study examining predictors for the outcome of steroid therapy or colectomy. Daperno et al. found early response to intensive steroid treatment in 57% of the acute episodes [2]. Slow steroid responders showed lower albumin levels, higher cumulative dose of glucocorticosteroids in the year prior to admission and higher age compared to early responders. Bernal et al. revealed that only blood in stool and more than six motions per day after 3 days of treatment were independent predictive factors of steroid refractoriness [3]. Previous works found increased inflammation on colonic biopsy, corticosteroid use, incomplete response to medical therapy, and medical hospitalization as significant predictors for colectomy [4–6]. In our previous study, we evaluated the long-term colectomy rate and determined predictive factors for inefficiency of steroid therapy and colectomy in our patients hospitalized for the first time because of severe flare-up of UC [7]. Clinical response to steroid therapy was achieved in 110 of the 183 enrolled patients with acute severe UC. About 14.5% of steroid responder patients were operated on during the average 4.4 years follow-up period. About 39.7% of patients in the steroid-refractory group needed either urgent or late colectomy. The overall colectomy rate was 24.6%. Low hematocrit, hemoglobin (Hgb) and serum iron levels, blood transfusion and increased erythrocyte sedimentation rate (ESR) were associated with the inefficiency of the intravenous steroid therapy. Unresponsiveness to intravenous steroid therapy, anemia, and the need for blood transfusion proved to be the major predictors for colectomy. In the study of Han et al., severe UC patients were associated with a 22.6% risk of nonresponse to intravenous corticosteroid at day 7. Among those parameters measured at day 3, the partial Mayo score, bowel movements, blood in stools, abdominal pain, high C-reactive protein, lower Hgb, high platelet count, and high ESR were associated with nonresponse in the univariate analysis. However, in the multivariate analysis, only the partial Mayo score at day 3 was the independent predictor of response to steroids at day 7. They follow-up data showed that an initial good response to steroid therapy tended to be associated with favorable outcomes later. About 19.4% of the patients with severe UC required colectomy within 1 year. Our results showed that the colectomy rate was 2.5 times higher in patients with acute severe UC who were not responding to the intensive steroid therapy. Based on these data, we do think that disease activity accompanied with anemia and higher inflammatory laboratory parameters assessed within a few days after starting systemic steroids suggests response to the therapy and may determine the long-term outcome in acute, severe UC.