A recent study (S Choshen et al. JPGN 2016; 63: 58-64) examined 283 children who were treated with IV steroids for acute severe ulcerative colitis. This study focused on steroid dosing. Their conclusion: “there does not seem to be a consistent superiority of high dose (>2 mg/kg/day) versus standard (1.25 mg/kg/day) or low-dose (1 mg/kg/day) methylprednisolone in pediatric acute severe colitis.”
Before looking into the details a little closer, one finding that was not even discussed in the abstract or discussion was the colectomy rate of 31%. Previous pediatric studies of patients with ulcerative colitis had found rates generally half that rate but notably included patients with milder presentations of ulcerative colitis. Thus, this rate of 31% (by 1 year after discharge) is useful information to reference when considering pediatric patients with acute severe colitis (ACS).
This study used datasets from the prospective Outcome of Steroid therapy in Colitis Individuals (OSCI) (n=128) and from the retrospective OSCI study (n=99).
- By day 5 of steroids, 45% had at most mild disease (ie PUCAI <35)
- 31% had failed IV steroids and required salvage therapy (biologic or calcineurin inhibitor)
- 20% had colectomy by discharge
- When examining steroid dosage and outcomes, the authors could not discern any differences in need for salvage therapy, PUCAI <35 at day 5, or need for salvage therapy within 1 year. There was a mild difference in length of stay with 9 days in the low-dose group and 10-days in the high dose group.
My take: This large cohort provides some reassurance that current steroid dosing recommendations are probably right, in that there was no discernible improvement with higher doses. This is in agreement with previous studies in adults which have not shown advantages of methylprednisolone >60 mg/day. The high colectomy rate of 31% is worth keeping in mind in this population.
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