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Is it always necessary to wait until day 5 for second line treatment in children with acute severe ulcerative
Luca Scarallo1, Arianna Bedeschi1, Martina Di Benedetto1
1Gastroenterology and Nutrition Unit, Meyer Children's Hospital IRCCS, Florence, Italy.
Insights
Pediatric acute severe ulcerative colitis (ASUC) flare-ups may need earlier treatment escalation. A day 3 Pediatric Ulcerative Colitis Activity Index (PUCAI) score of 50 or higher can predict intravenous corticosteroid failure.
Area of Science:
- Pediatric Gastroenterology
- Inflammatory Bowel Disease Research
- Clinical Trial Methodology
Background:
- Current ECCO-ESPGHAN guidelines suggest delaying second-line therapy for pediatric acute severe ulcerative colitis (ASUC) until day 5 of intravenous corticosteroids (IVCS).
- This approach may not be optimal for all patients, particularly those experiencing disease flares.
Purpose of the Study:
- To identify early clinical indicators of IVCS failure in pediatric ASUC.
- To assess if the day 3 Pediatric Ulcerative Colitis Activity Index (PUCAI) can guide earlier treatment escalation.
Main Methods:
- A multicenter retrospective study analyzed data from biologic-naïve children hospitalized with ASUC between 2015 and 2024.
- Logistic regression identified predictors of IVCS failure, and ROC analysis evaluated the day 3 PUCAI's performance.
Main Results:
- Of 91 patients, 49.5% required second-line therapy. IVCS failure was significantly higher in ASUC during disease flares (71.1%) compared to initial diagnosis (37.0%).
- In flare-ASUC patients, a day 3 PUCAI score ≥50 predicted IVCS non-response with high specificity (94.1%) and sensitivity (75.0%).
- Patients with a day 3 PUCAI ≥50 had lower colectomy-free rates and reduced likelihood of achieving clinical remission.
Conclusions:
- A day 3 PUCAI score of ≥50 in pediatric ASUC flare patients indicates a need for earlier risk stratification.
- This score may prompt earlier preparation for potential second-line rescue therapies, improving outcomes.
Background:
ECCO-ESPGHAN guidelines for pediatric acute severe ulcerative colitis (ASUC) recommend delaying second-line therapy until day 5 of intravenous corticosteroids (IVCS).
Aims:
To identify early clinical predictors of IVCS failure in pediatric ASUC and evaluate whether day 3 PUCAI could support earlier treatment escalation.
Methods:
This multicenter retrospective study included biologic-naïve children hospitalized for ASUC between 2015 and 2024. Demographic, clinical, laboratory, and treatment data at diagnosis and during hospitalization were retrieved. Logistic regression identified predictors of IVCS failure, while ROC analysis evaluated day 3 PUCAI performance.
Results:
Ninety-one patients were included (44.6% male; median age 13.3 years); 45 (49.5%) required second-line therapy. IVCS failure was less frequent in ASUC at diagnosis than during disease flare (37.0%vs 71.1%;p = 0.001). ASUC during disease flare was associated with higher odds of IVCS failure, although statistical significance was not reached (aOR 3.39, 95%CI 0.99-11.9;p = 0.051). In flare-ASUC patients, day 3 PUCAI ≥50 predicted IVCS non-response (94.1% specificity, 75.0% sensitivity, positive likelihood ratio of 12.8). Patients with PUCAI ≥50 had lower colectomy-free rates and probability of achieving clinical remission (p < 0.05).
Conclusions:
A day 3 PUCAI ≥50 in children with flare-ASUC may warrant earlier risk stratification and preparation for potential second-line rescue therapy.
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