New research presented at the Advances in Inflammatory Bowel Diseases (AIBD) 2021 Annual Meeting in December 2020 has suggested that the albumin, C-reactive protein (CRP) and endoscopy (ACE) index may come to the aid of the physician to ascertain the response of patients with acute severe ulcerative colitis to steroid treatment.¹

Researchers from Portugal retrospectively examined the effectiveness of the ACE index in predicting the response to steroids in 65 patients with acute severe ulcerative colitis at the time of hospital admission. Study included 65 patients who were hospitalized between January 2005 and December 2020.

Calculation of the ACE Index is based on three parameters: CRP ≥50mg/dL, albumin ≤30g/L and increased endoscopic severity (Mayo endoscopic score=3). The score ranges between 0 and 3 points. Acute ulcerative colitis patients who score 3 on the ACE index are at a high risk of not responding to steroid treatment.

Out of the 65 patients included in the study, 78.5% responded to steroids. A significant difference was noted in the mean CRP (108.0  vs. 66.0 mg/dL, respectively), and albumin (2.9 vs. 3.4 g/L), levels as well as the endoscopic severity score between the patients who did not respond to steroid treatment and those who responded. But no significant difference in the Ulcerative Colitis Endoscopic Index of Severity (UCEIS) score was noted between the responders and nonresponders (8 vs 7).

The median ACE index was calculated to be 2. The ACE index was found to be a predictor of steroids response (AUC 0.789). Fifty percent of the patients with a score of 3 showed no response to steroid treatment. On the other hand,  86.3% of patients with scores below 3 responded to steroids.

Parenteral steroids are the first-line treatment for patients with acute ulcerative colitis. But some patients do not improve with this line of management.

This study has shown that the ACE index is a simple and easy tool to accurately identify those patients with acute ulcerative colitis who are at risk of not responding to steroids. Patients with a higher ACE index score at the time of hospital admission were less likely to respond to steroids. Early risk stratification would mean prompt institution of second-line “rescue” medical treatment or surgical intervention rather than putting them on a trial of steroids. However, the authors also note that the score “did not distinguish which high-risk patients would benefit from earlier therapeutic escalation" since only 50% of patients with an ACE index score of 3 did not respond to steroids.

Reference

1. Freitas M, et al. P051 Identifying high-risk patients with acute severe ulcerative colitis: Is the ACE Index useful? Am J Gastroenterol. 2021 Dec 1;116(Suppl 1):S13. doi: 10.14309/01.ajg.0000798804.53697.05.