Russell Cohen, MD, on Caring for the Hospitalized Patient With Ulcerative Colitis

Dr Cohen reviews his presentation at the Advances in IBD regional meeting on caring for hospitalized patients with ulcerative colitis, including therapeutic options and consultation with surgery.

Russell Cohen, MD, is a professor of medicine and director of the IBD Center at the University of Chicago.

TRANSCRIPT:

Dr. Russell Cohen:  Hi, I'm Dr. Russell Cohen. I'm a professor of medicine and director of the IBD Center at the University of Chicago. At the Advances in IBD Regional meeting, one of my lectures was on the hospitalized patient with severe ulcerative colitis.

This is an important topic, as many of us are faced with these patients who come in acutely ill to the hospital. It's important to remember that our goal is to get patients better, to keep them well, and when they're discharged to make sure they're well enough to be discharged.

Please realize that many of these patients may require surgery either during or shortly after that hospitalization. Consultation with an expert IBD surgeon is highly recommended. Most of the time, we give these patients IV steroids. It is a good rule to expect patients to start responding to any therapy within 48 to 72 hours.

Presuming the patient doesn't have an infection, which you should have already ruled out, high-dose IV steroids, typically 40 to 60 Solu-Medrol, or equivalent to hydrocortisone, given either as continuous infusion or throughout the day should rapidly work in most of these patients.

For patients who do not have a response to these therapies within the first 48 to 72 hours, it's important for you and the patient to determine whether they go to surgery at that point or are you going to try a medication.

For many years, the medication that we'd use is intravenous cyclosporine. Cyclosporine is highly effective, 80-plus% response rates, although the maintenance needs to be with a different therapy, such as azathioprine, 6-MP, perhaps methotrexate—although, more commonly, we've been using vedolizumab.

Another option, perhaps, if patients haven't been that sick, could be oral cyclosporine or even oral tacrolimus. Personally, we use oral tacrolimus a lot at the University of Chicago, as it's easier to dose and safer and very easy to get levels.

Many of you may have tried or have been successful with infliximab in an inpatient setting. Often, this is an effective option but less so if the patient has already had protein-losing enteropathies, very low albumin, losing a lot of protein in the stool.

Studies have shown that while some patients do well with infliximab, many might need escalating doses, a few doses up front, to keep them well. There's no data supporting a higher dose than 5mg/kg as an initial dose, although checking a level 3 days later, even if you don't get the results back right away, may be helpful for you to know whether the body is retaining the medicine. Unfortunately, high-dose loading protocols with adalimumab have not been found to be effective.

The only other therapy that recently has gained some attention is oral tofacitinib. Tofacitinib is FDA-approved for moderate to severe ulcerative colitis and some groups have given the ulcerative colitis dosing 10 mg twice a day, and more recently, even 10 mg 3 times a day to these patients. It seems that the 10 mg 3 times a day dosing may be effective. However, we do caution you against the safety of using such a high dose considering that clinical trials previously pulled that dose due to safety concerns.

The important thing is the patients need to be well when they go home. Do not send a sick patient home. Well means normal bowel movements, no pain, no blood, formed stools, able to eat.

This is Dr. Russell Cohen from the University of Chicago. Thank you for joining us with the Advances in IBD Regional meetings. We hope that we found that all of these lectures have been helpful to you in your careers and your practices.