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P453 Long-term clinical impact of early introduction of granulocyte and monocyte adsorptive apheresis in new onset ulcerative colitis
Clinical: Therapy and observation P452 Long-term efficacy and safety of cyclosporine as a rescue therapy in acute, steroid-refractory severe ulcerative colitis A. Balint1 *, K. Farkas1 , Z. Szepes1 , F. Nagy1 , S. Monika2 , T. Wittmann1 , T. Molnar1 . 1 University of Szeged, First Department of Medicine, Szeged, Hungary, 2 University of Szeged, Department of Medical Physics and Informatics, Szeged, Hungary Background: Although cyclosporine is an accepted and effective therapeutic choice in patients with severe ulcerative colitis (UC), long term colectomy rate varies between 60 88% among patients in whom cyclosporine initially induced remission. The aim of our study was to evaluate the long-term outcome and the optimal duration of cyclosporine therapy in patients with acute, severe UC. Methods: 73 (40 females, 33 males; mean age at the diagnosis 31.7 years, mean disease duration 13.4 years) of 183 patients hospitalized for severe exacerbation of UC between January 1998 and June 2009 revealed steroid-refractory after intravenous methylprednisolone therapy. They underwent intravenous cyclosporine treatment for 5 days following oral treatment in the case of a good initial response. Results: The mean follow up after the initiation of cyclosporine therapy was 4.2 years. The median duration of cyclosporine therapy was 9.6 months. Side effects developed in 37 patients. 20 patients underwent early colectomy. Cyclosporine therapy had to be discontinued due to intolerable or severe side effects in 22 patients. Cyclosporine failed and late colectomy was performed in 14 of the 53 responders during the longterm follow up. Duration of cyclosporine treatment was significantly longer in those who avoided colectomy (5.4 vs. 13.3 months, p = 0.009). The optimal cut-point of the duration of cyclosporine therapy to avoid colectomy was 4.5 months. No association was revealed between the duration of cyclosporine therapy and the development of side effects. Conclusions: Cyclosporine is effective in acute, severe UC. After a median follow up of more than 4 years, 53.4% of the patients remained colectomy free. The optimal time for cyclosporine treatment proved to be 4.5 months. P453 Long-term clinical impact of early introduction of granulocyte and monocyte adsorptive apheresis in new onset ulcerative colitis T. Yamamoto1 *, M. Shiraki1 , S. Umegae1 , K. Matsumoto1 . 1 Yokkaichi Social Insurance Hospital, Inflammatory Bowel Disease Centre, Yokkaichi, Japan Background: The efficacy of granulocyte and monocyte adsorptive apheresis (GMA) for patients with a first episode of ulcerative colitis (UC) has been scarcely reported. This study was to see if the introduction of GMA at an early stage reduces corticosteroid administration and steroid dependency in the long term clinical course of UC. Methods: Forty consecutive patients with moderately active symptoms as the first attack of UC were included. Twenty patients were treated with GMA, with or without corticosteroids (GMA group), and the other 20 were given corticosteroids without GMA (steroid group). GMA with the Adacolumn (90 minutes/session, at 30 mL/minute) was administered weekly. Patients who did not achieve clinical remission (normal stool frequency and no rectal bleeding) after 5 GMA sessions were given 5 additional sessions. All patients were monitored for 5 years. Relapses were treated in the same manner as the first attack in both groups. The total dose of steroid administered and the appearance of steroid-dependency were to be compared between the two groups. Results: Patients were well matched between the groups with respect to age, sex, duration of symptoms before entry,
S191 disease activity index score, medications before entry, and extraintestinal manifestations. All patients in both groups achieved clinical remission after the first attack. The mean number of relapses per patient was 2.8 in the GMA group and 2.9 in the steroid group (P = 0.86). During this study, 5 patients in the GMA group did not require corticosteroids. The mean dose of steroid administered during the 5 years was 2,141 mg in the GMA group vs 5,443 mg in the steroid group (P = 0.002). One patient in the GMA group and 7 in the steroid group were steroid-dependent at the end of the study (P = 0.048). Conclusions: In patients with the first UC episode, GMA therapy at an early stage significantly reduces steroid administration and steroid-dependency in the long-term clinical course. P454 Leucocytosis due to azathioprine in a patient with Crohn’s disease D.G. Duman1 *, E. Bicakci1 . 1 Saglik Bakanligi Marmara Universitesi EAH, Gastroenterology, Istanbul, Turkey Background: Azathioprine is commonly prescribed for inflammatory bowel disease. Although the most common side effect reported with azathioprine treatment is leukopenia due to the myelosuppression, early isolated leucocytosis has not been described before. We describe a patient who developed leucocytosis within the first 3 days after the initiation of azathioprine. Methods: A 39-year-old woman with a 10-year history of Crohn’s disease was complaint of chronic diarrhoea, abdominal pain and rectal bleeding. She never received immunomodulatory therapy before. Upon diagnosis she had been treated with meselamine of low dose (1.5 g/day) for the last 10 years. Physical examination was not remarkable except the cachectic appearance (body weight: 45 kg). She had anaemia of haemoglobin level of 11.2 g/dL with normal white blood cell (WBC) count. Her colonoscopic examination and biopsies revealed Crohn’s disease of ileo-colonic involvement and perianal fistulas. It was decided to start with ciprofloxacin and metronidazole. Following the initial work-up for infection, azathioprine 50 mg daily was added. After the third dose of azathioprine her WBC increased abruptly to 20.5×103 /mm3 . She did not have fever or any other constitutional symptom of infection. Her repeated WBC counts were consistently high around 20×103 /mm3 and peripheral blood smear showed 68% neutrophil, 28% lymphocytes, 6% monocytes and 1% eosinophil with negative C-reactive protein. Thus azathioprine dose was withheld but the antibiotics were continued. Her urinary culture resulted negative for infection. Three days after stopping azathioprine her WBC returned to normal. Results: After discontinuation of azathioprine, her long-term follow-up for 2.5 years with infliximab-only treatment has been excellent with remission of both the mucosal disease and fistulas. Conclusions: To our knowledge, this is the first reported case of azathioprine toxicity with leucocytosis the mechanism of which is unclear. Clinicians should be aware of the possibility of unexpected increase in WBC counts in IBD patients prescribed azathioprine. P455 Lessons learnt from the design and implementation of a web-based intervention to support self-management in inflammatory bowel disease (IBD) C. Calvert1 *, S. Lal2 , C. Stansfield2 , J. McLaughlin1 , A. Robinson2 . 1 Manchester University, School of Translational Medicine, Manchester, United Kingdom, 2 Salford Royal Foundation Trust, Gastroenterology, Salford, United Kingdom Background: Engaging and empowering patients to have greater involvement in their care is central to the vision of
S191 disease activity index score, medications before entry, and extraintestinal manifestations. All patients in both groups achieved clinical remission after the first attack. The mean number of relapses per patient was 2.8 in the GMA group and 2.9 in the steroid group (P = 0.86). During this study, 5 patients in the GMA group did not require corticosteroids. The mean dose of steroid administered during the 5 years was 2,141 mg in the GMA group vs 5,443 mg in the steroid group (P = 0.002). One patient in the GMA group and 7 in the steroid group were steroid-dependent at the end of the study (P = 0.048). Conclusions: In patients with the first UC episode, GMA therapy at an early stage significantly reduces steroid administration and steroid-dependency in the long-term clinical course. P454 Leucocytosis due to azathioprine in a patient with Crohn’s disease D.G. Duman1 *, E. Bicakci1 . 1 Saglik Bakanligi Marmara Universitesi EAH, Gastroenterology, Istanbul, Turkey Background: Azathioprine is commonly prescribed for inflammatory bowel disease. Although the most common side effect reported with azathioprine treatment is leukopenia due to the myelosuppression, early isolated leucocytosis has not been described before. We describe a patient who developed leucocytosis within the first 3 days after the initiation of azathioprine. Methods: A 39-year-old woman with a 10-year history of Crohn’s disease was complaint of chronic diarrhoea, abdominal pain and rectal bleeding. She never received immunomodulatory therapy before. Upon diagnosis she had been treated with meselamine of low dose (1.5 g/day) for the last 10 years. Physical examination was not remarkable except the cachectic appearance (body weight: 45 kg). She had anaemia of haemoglobin level of 11.2 g/dL with normal white blood cell (WBC) count. Her colonoscopic examination and biopsies revealed Crohn’s disease of ileo-colonic involvement and perianal fistulas. It was decided to start with ciprofloxacin and metronidazole. Following the initial work-up for infection, azathioprine 50 mg daily was added. After the third dose of azathioprine her WBC increased abruptly to 20.5×103 /mm3 . She did not have fever or any other constitutional symptom of infection. Her repeated WBC counts were consistently high around 20×103 /mm3 and peripheral blood smear showed 68% neutrophil, 28% lymphocytes, 6% monocytes and 1% eosinophil with negative C-reactive protein. Thus azathioprine dose was withheld but the antibiotics were continued. Her urinary culture resulted negative for infection. Three days after stopping azathioprine her WBC returned to normal. Results: After discontinuation of azathioprine, her long-term follow-up for 2.5 years with infliximab-only treatment has been excellent with remission of both the mucosal disease and fistulas. Conclusions: To our knowledge, this is the first reported case of azathioprine toxicity with leucocytosis the mechanism of which is unclear. Clinicians should be aware of the possibility of unexpected increase in WBC counts in IBD patients prescribed azathioprine. P455 Lessons learnt from the design and implementation of a web-based intervention to support self-management in inflammatory bowel disease (IBD) C. Calvert1 *, S. Lal2 , C. Stansfield2 , J. McLaughlin1 , A. Robinson2 . 1 Manchester University, School of Translational Medicine, Manchester, United Kingdom, 2 Salford Royal Foundation Trust, Gastroenterology, Salford, United Kingdom Background: Engaging and empowering patients to have greater involvement in their care is central to the vision of