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Acute severe ulcerative colitis in children: a systematic review
1Pediatric Gastroenterology Unit, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel. turnerd@szmc.org.il
Inflammatory Bowel Diseases
|July 21, 2010
Summary
Pediatric ulcerative colitis (UC) is severe, with a 34% steroid-failure rate. Early use of the Pediatric UC Activity Index (PUCAI) guides treatment, with biologics like infliximab offering effective alternatives to cyclosporine.
Area of Science:
- Pediatric Gastroenterology
- Inflammatory Bowel Disease Research
- Clinical Trial Analysis
Background:
- Pediatric ulcerative colitis (UC) presents with a more severe phenotype, characterized by extensive disease and frequent acute severe exacerbations.
- A significant pooled steroid-failure rate of 34% (95% CI: 27%-41%) highlights the need for effective management strategies in children.
Purpose of the Study:
- To review and synthesize current evidence on managing severe pediatric ulcerative colitis.
- To provide guidance on corticosteroid dosing, the role of nutritional support, interpretation of imaging, and the utility of activity indices.
- To evaluate the efficacy of second-line therapies including cyclosporine and infliximab, and to discuss surgical considerations.
Main Methods:
- Systematic review and meta-analysis of pooled data from multiple studies on pediatric UC.
- Analysis of steroid-failure rates, efficacy of immunosuppressants and biologics, and outcomes of colectomy.
- Utilized the Pediatric UC Activity Index (PUCAI) for predicting treatment response and guiding therapy escalation.
Main Results:
- Pooled steroid-failure rate in 291 children was 34%. Recommended corticosteroid dosing: 1-1.5 mg/kg daily (up to 40-60 mg).
- The Pediatric UC Activity Index (PUCAI) at day 3 (>45 points) predicts steroid failure, and at day 5 (>65-70 points) indicates need for second-line therapy.
- Cyclosporine (81% short-term success) and infliximab (75% short-term response, 64% 1-year response) are effective, with cyclosporine use limited to 3-4 months bridging to thiopurines.
Conclusions:
- Early assessment using PUCAI is crucial for timely escalation of therapy in pediatric UC.
- Biologic therapies like infliximab offer comparable efficacy to cyclosporine, providing valuable options for refractory cases.
- Colectomy is a consideration for toxic megacolon, medically refractory disease, or chronic severe cases, requiring careful evaluation of long-term outcomes and quality of life.
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