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Data regarding the influence of prednisolone tapering on clinical outcomes among patients with ulcerative colitis (UC) are limited. We aimed to investigate the influence of different prednisolone tapering algorithms on the effectiveness of infliximab (IFX) among patients with UC.

This Danish retrospective single-center study included all patients with UC who were treated with IFX between 2009 and 2019 at Herlev University Hospital. The patients were grouped according to the prednisolone tapering: standard (≤5 mg/week), fast (>5 mg/week), or direct discontinuation after an initial course of less than one week. Finally, we included a control group of patients treated with IFX monotherapy. The primary outcome was corticosteroid-free clinical remission at weeks 14 and 52 defined as a partial Mayo score ≤1. Variables with a p-value ≤0.20 in univariable regression analysis were included in multivariable analysis. A subgroup analysis containing patients with acute severe ulcerative colitis (ASUC) treated with at least 40 mg of prednisolone at initiation of IFX was performed.

The study included 148 patients with UC of whom 81 (54.7%) were treated with prednisolone at the initiation of IFX. No association between prednisolone tapering and corticosteroid-free clinical remission with IFX at weeks 14 or 52 was observed (Figure 1 and Table 2). However, a higher proportion of patients in the standard tapering group achieved a C-reactive protein (CRP) level less than 5 mg/L at week 14 as compared with the fast-tapering group (23/23 (100%) vs. 14/18 (77.8%); p=0.03) and directly discontinuation group (6/10 (60%); p=0.03). This difference was not explained by prednisolone usage. In addition, none of the patients within the standard tapering regime (0/24; 0%) had severe activity at week 14 whereas this was seen in 4/19 (21.1%) in the fast tapering regime (p=0.03). In the subgroup analysis of 33 patients with ASUC, the standard tapering algorithm was associated with higher clinical remission as compared with the fast tapering regime at week 14 (9/14 (64.3%) vs. 5/19 (27.8%); p=0.02) and clinical response or remission at week 52 (12/14 (85.7%) vs. 7/19 (36.8%); p=0.01, Figure 2).

This study demonstrated no overall impact of prednisolone tapering algorithms on short and long-term effectiveness of IFX in patients with UC. However, standard tapering resulted in lower CRP levels and fewer cases of severe disease activity in the overall cohort and higher rate of short and long-term clinical response among ASUC patients, as compared with fast tapering regimes. Taken together, the data indicate that longer corticosteroid exposure in patients with high disease burden might improve IFX responses.

Educational objectives

1-    To understand that IBD are associated with worse quality of life and high rates of depression, beyond symptoms alone.

2-    To consider the role of psychological components on postoperative outcomes

3-    To understand the rationale and results of our study

4-    To understand the rationale for preoperative psychological support in IBD patients

Summary

Background: Inflammatory bowel diseases lead to increased rates of depression and reduced quality of life (QoL), beyond intestinal symptoms alone. QoL seems to improve at 1 year after surgery, but not in the short term. No studies have explored the potential role of psychological components (mindfulness in particular) on postoperative outcomes. 

Aim: the aim of this pilot-study was to explore the correlation between a set of psychological predictors, QoL and surgical outcomes.

Methods: psychological questionnaires were administered before surgery. QoL questionnaires were administered both preoperatively and at 30- 90 days and 6 months after surgery. Length of stay (LOS), postoperative pain and complications were also evaluated. 

Results: 30 patients were enrolled(56% Crohn’s - CD, 44% ulcerative colitis - UC). 67% were males. Mean age was 43,5, mean BMI 22,6. Most patients were ASA 2(70%). Smoke habit was reported in 17%. Charlson Comorbidity Index was 0 in 54% of patients, 1 in 23%, 2 in 17%, 3 in 3% and > 5 in 3%. Index procedure was ileocecal resection in 47% of cases, total colectomy in 13% and restorative proctectomy in 40%. Mean operative time was 186 minutes. In 53% of patients a temporary stoma was performed. No differences in baseline psychological characteristics were found between CD and UC patients. Higher levels of stress(PSS) (P=0.0008), anxiety(HADS-A)(P=0.028) and depression (HADS-D)(P=0.028)were correlated with worse preoperative QoL. No correlation was found between preoperative psychological predictors and LOS, postoperative pain and functional recovery (time to 1° bowel movement). However, the logistic regression model found a correlation between postoperative complications and Anxiety(HADS-A). Patients experienced a significant increase in QoL after surgery(30 days, P=0.008; 90 days, P=0.005). Patients with higher QoL and Cognitive Flexibility Scale scores at baseline had more probabilities to experience a significant improvement 30 and 90 days after surgery(P<0.0001; P=0.04).

Conclusions: stress, anxiety and depression impacted on preoperative QoL. Anxiety correlated with postoperative adverse outcomes. Cognitive flexibility had a positive effect on QoL improvement at 30 and 90 days after surgery. Patients with higher baseline QoL were more susceptible to improve their QoL over time after surgery. 

-          To review the frequency and type of pancreatic manifestations in IBD

-          To have an overview of the morphological features of chronic and autoimmune pancreatitis

-          To emphasise the role of histopathology in the diagnosis of pancreatic manifestations in IBD

Pancreatic changes are present in up to 50% of IBD patients, but symptomatic disease is rare and mostly related to acute pancreatitis, chronic pancreatitis or autoimmune pancreatitis.

Acute pancreatitis in patients with IBD is usually related to gallstones or drugs (thiopurines, mesalamine) and is more common in Crohn’s disease (CD) than in ulcerative colitis (UC).

Chronic pancreatitis is quite rare and thought to be idiopathic or possibly related to obstruction, e.g. in patients with primary sclerosing cholangitis. There is no possibility to specifically diagnose IBD-associated chronic pancreatitis, and diagnosis is usually one of exclusion.

Autoimmune pancreatitis (AIP) is more frequent in IBD patients than in the general population, but it remains a rare disease. IBD, and especially UC, are most frequently associated with type 2 (= non IgG4-related) AIP and this association is characterized by an active and more aggressive disease with higher rates of colectomies. There are definite histopathologic criteria for the diagnosis of AIP, which can be successfully applied on biopsy material. Therefore, if AIP is suspected in IBD patients, a pancreatic biopsy can be useful to confirm the diagnosis and direct therapy.