BMJ Open Gastroenterol. 2022 Jan;9(1):e000763.doi: 10.1136/bmjgast-2021-000763.

Shaji Sebastian ^1 2, Kamal V Patel ³, Jonathan P Segal ⁴, Sreedhar Subramanian ^5 6, Thomas Edward Conley ⁷, Haidee Aleman Gonzalez ⁸, Alexandra J Kent ⁹, Aamir Saifuddin ¹⁰, Lucy Hicks ¹¹, Shameer Mehta ¹², Neeraj Bhala ^13 14, Matthew J Brookes ^15 16, Christopher A Lamb ^17 18, Nicholas A Kennedy ^19 20, PROTECT ASUC collaborators; Gareth J Walker ²¹

Author information

¹IBD Unit, Department of Gastroenterology, Hull University Teaching Hospitals NHS Trust, Hull, UK Shaji.sebastian4@nhs.net.

²Hull York Medical School, Hull, UK.

³Department of Gastroenterology, St George's University Hospitals NHS Trust, London, UK.

⁴Department of Gastroenterology, St Marks Hospital, London, UK.

⁵Department of Gastroenterology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK.

⁶Univeristy of Liverpool, Liverpool, UK.

⁷Gastroenterology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK.

⁸IBD Unit, Department of Gastroenterology, Hull University Teaching Hospitals NHS Trust, Hull, UK.

⁹Gastroenterology, King's College Hospital NHS Foundation Trust, London, UK.

¹⁰Gastroenterology, Kings College Hospital, London, UK.

¹¹Gastroenterology, Imperial College Healthcare NHS Trust, London, UK.

¹²Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK.

¹³Gastroenterology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK.

¹⁴Institute of Applied Health Research, University Of Birmingham, Birmingham, UK.

¹⁵Gastroenterology, Royal Wolverhampton NHS Trust, Wolverhampton, UK.

¹⁶University of Wolverhampton, Wolverhampton, UK.

¹⁷Newcastle University, Newcastle upon Tyne, UK.

¹⁸Gastroenterology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK.

¹⁹Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.

²⁰IBD Pharmacogenetics, University of Exeter, Exeter, UK.

²¹Gastroenterology, Torbay and South Devon NHS Foundation Trust, Torquay, UK.

Abstract

Introduction: Acute severe ulcerative colitis (ASUC) traditionally requires inpatient hospital management for intravenous therapies and/or colectomy. Ambulatory ASUC care has not yet been evaluated in large cohorts.

Aims: We used data from PROTECT, a UK multicentre observational COVID-19 inflammatory bowel disease study, to report the extent, safety and effectiveness of ASUC ambulatory pathways.

Methods: Adults (≥18 years old) meeting Truelove and Witts criteria between 1 January 2019-1 June 2019 and 1 March 2020-30 June 2020 were recruited to PROTECT. We used demographic, disease phenotype, treatment outcomes and 3-month follow-up data. Primary outcome was rate of colectomy during the index ASUC episode. Secondary outcomes included corticosteroid response, time to and rate of rescue or primary induction therapy, response to rescue or primary induction therapy, time to colectomy, mortality, duration of inpatient treatment and hospital readmission and colectomy within 3 months of index flare. We compared outcomes in three cohorts: (1) patients treated entirely in inpatient setting; ambulatory patients subdivided into; (2) patients managed as ambulatory from diagnosis and (3) patients hospitalised and subsequently discharged to ambulatory care for continued intravenous steroids.

Results: 37% (22/60) participating hospitals used ambulatory pathways. Of 764 eligible patients, 695 (91%) patients received entirely inpatient care, 15 (2%) patients were managed as ambulatory from diagnosis and 54 (7%) patients were discharged to ambulatory pathways. Aside from younger age in patients treated as ambulatory from diagnosis, no significant differences in disease or patient phenotype were observed. The rate of colectomy (15.0% (104/695) vs 13.3% (2/15) vs 13.0% (7/54), respectively, p=0.96) and secondary outcomes were similar among all three cohorts. Stool culture and flexible sigmoidoscopy were less frequently performed in ambulatory cohorts. Forty per cent of patients treated as ambulatory from diagnosis required subsequent hospital admission.

Conclusions: In a post hoc analysis of one of the largest ASUC cohorts collected to date, we report an emerging UK ambulatory practice which challenges treatment paradigms. However, our analysis remains underpowered to detect key outcome measures and further studies exploring clinical and cost-effectiveness as well as patient and physician acceptability are needed.

Trial registration number: NCT04411784.