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The pediatric ulcerative colitis activity index (PUCAI) predicts steroid-failure in adults with acute severe colitis
Ohad Atia1, Arun Gupta2, Simon Travis3
1Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel.
Insights
The Pediatric Ulcerative Colitis Activity Index (PUCAI) effectively predicts intravenous corticosteroid (IVCS) failure in acute severe ulcerative colitis (ASC). A PUCAI score of 45 on day 3 indicates likely failure, guiding timely second-line therapy decisions.
Area of Science:
- Gastroenterology
- Clinical Medicine
- Pediatric Research (applied to adults)
Background:
- Acute severe ulcerative colitis (ASC) treatment often involves intravenous corticosteroids (IVCS).
- A significant proportion of ASC patients (one-third) do not respond to IVCS, necessitating alternative treatments or surgery.
- Predictive tools are crucial for early identification of non-responders to optimize ASC management.
Purpose of the Study:
- To evaluate the Pediatric Ulcerative Colitis Activity Index (PUCAI) for predicting IVCS response in adult ASC patients.
- To establish a two-step decision-making framework for initiating second-line therapy in ASC.
Main Methods:
- Retrospective multicenter cohort study involving adult ASC patients.
- Assessment of PUCAI scores, Oxford criteria, and Swedish index at baseline, days 3 and 5, and discharge.
- Correlation of index scores with treatment outcomes, including need for second-line therapy and colectomy.
Main Results:
- 153 adult ASC patients were analyzed; 33% required second-line therapy and 15% underwent colectomy.
- Non-responders exhibited significantly higher median PUCAI scores on days 3 and 5 compared to responders (p < .001).
- PUCAI demonstrated strong predictive values: PUCAI ≥ 45 on day 3 (NPV 83%) and PUCAI ≥ 65 on day 5 (PPV 100%) for IVCS failure.
Conclusions:
- The PUCAI is a highly effective tool for predicting IVCS failure in adult ASC.
- A PUCAI score ≥ 45 on day 3 offers excellent negative predictive value, signaling the need for second-line therapy consideration.
- A PUCAI score ≥ 65 on day 5 provides high positive predictive value for initiating second-line therapy.
Background:
One-third of patients with acute severe ulcerative colitis (ASC) fail to respond to intravenous corticosteroids (IVCS) and require second-line therapy or colectomy. We aimed to explore the performance of the Pediatric Ulcerative Colitis Activity Index (PUCAI), for predicting response to IVCS in adults with ASC, and to base a two-step decision-making process for guiding the introduction of second-line therapy.
Methods:
This was a retrospective multicenter cohort study of adult patients with ASC. PUCAI score, Oxford criteria, and Swedish index were determined at baseline, day three and five of hospitalization, and discharge when outcomes were ascertained.
Results:
153 patients were included (mean age 34.7 ± 14.6, median disease duration 7.8 years [IQR 0-17.4]), of whom 51 (33%) required second-line therapy, and 23 (15%) eventually underwent colectomy by discharge. At days three and five, the median PUCAI scores were higher in non-responders compared with responders (55 [45-69] vs. 38 [25-55] at day 3, and 55 [36-65] vs. 20 [5-30] at day 5; both p < .001). The negative and positive predictive values (NPV and PPV) of IVCS failure were 76/63% for the Oxford criteria, 83/52% for the Swedish index as determined on day 3, and 73/100% for PUCAI ≥ 65 points on day five. The corresponding figures for PUCAI ≥ 45 at day 3 were 83/54%.
Conclusion:
The PUCAI is a highly predictive tool for IVCS failure. PUCAI ≥ 45 on day 3 has an excellent NPV for IVCS failure indicating preparation for second-line therapy, and PUCAI ≥ 65 on day 5 has a high PPV to initiate the therapy.
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