Steroids are often prescribed as initial short-term treatment for acute flare-ups in ulcerative colitis. They are the mainstay of treatment of acute severe ulcerative colitis, which is a medical emergency and requires prompt multidisciplinary management. However, steroids are a double-edged weapon and their prolonged use is associated with risk of adverse effects.

A recent retrospective single-center study has reported that ulcerative colitis patients who have used steroids in the past and have histologically active disease are more likely to experience a relapse of their disease.¹ Researchers from South Korea retrospectively analyzed data from 492 ulcerative colitis (mean age 48 years; nearly 52% males) to examine the risk of clinical relapse according to histologic activity (as measured by Geboes score) in patients with Mayo endoscopic subscore (MES) of either 0 or 1. Any change of drugs, hospitalization due to worsening of disease, or total colectomy during the follow-up period were considered as relapse for the purpose of this study.

Ninety-two patients (18.7%) suffered a clinical relapse that led to change in medication over a follow-up of median 549 days. Of these, 51.4% had MES score of 0 at the first endoscopy, 39.4% had used steroids previously (hazard ratio 1.76), and 70.5% showed histologic improvement with Geboes score of less than 3.1 (HR 1.73).

On multivariate analysis, history of steroid use increased the risk of relapse in patients with MES score of 1, with adjusted HR of 2.10. Histologic activity alone did not predict relapse. At one year, among patients with histologic improvement and no history of steroid use, the incidence of clinical relapse was 4.1%, whereas in patients with histologically active disease (Geboes score of ≥3.1) and history of steroid use, the incidence rate was nearly 24%. At two years, the corresponding figures were 10.6% versus 39.4%, respectively.

Assessment of disease activity is crucial for treatment planning. Histologic disease activity has been suggested as a better marker of disease activity than clinical or endoscopic activity.² The authors concluded that histologic activity and history of steroid use can help in risk stratification for relapse in ulcerative colitis.

References

1. Seong G, et al. Histologic activity and steroid use history are risk factors of clinical relapse in ulcerative colitis with Mayo endoscopic subscore of 0 or 1. Inflamm Bowel Dis. 2022 Apr 9;izac075. doi: 10.1093/ibd/izac075.
2. Pai RK, et al. The emerging role of histologic disease activity assessment in ulcerative colitis. Gastrointest Endosc. 2018 Dec;88(6):887-898.