Intestinal selective biologics help achieve severe treatment-naïve UC and moderately recurrent UC!

For medical professionals only

Ulcerative colitis (UC) is a chronic, nonspecific inflammatory disorder of the colorectal mucosa that is divided into primary (first episode without past medical history) and chronic relapsing (recurrent symptoms during clinical remission) of unknown etiology, with mucus, bloody stools being the most common symptom, and can cause structural bowel injury, stenosis, and/or loss of function ^[1-2].

Mild UC can use aminosalicylic acid preparations as the main drug; Hospitalization is required in 20% of patients with moderate or severe disease, and treatment options include aminosalicylate, hormones, immunosuppressants, and/or biologic agents
.
Even if initial treatment is successful, patients with UC often require long-term maintenance therapy, and biological therapy is an important step [^3].

Vedelizumab, an anti-α4β7 integrin, which selectively blocks lymphocyte transport to the intestine, is a first-line agent for the treatment of moderately to severely active UC and is indicated in patients who do not respond adequately or tolerate conventional therapy, significantly reduces the recurrence rate of UC, and has good safety and tolerability [^4-6].

In this issue, we invite Tian Li, deputy chief physician of the Third Xiangya Hospital of Central South University, to share two classic cases of UC and explore the therapeutic effect
of vedelizumab on severe treatment-naïve UC and moderate chronic relapsing UC.

About the author

Tian Li Deputy Chief Physician

• Deputy Director of the Department of Gastroenterology, Third Xiangya Hospital, Central South University

• Doctor of Medicine, Deputy Chief Physician, Master Supervisor

• Youth Committee Member of Digestive Endoscopy of Endoscopist Branch of Chinese Medical Doctor Association

• Member of Digestive Endoscopy Committee of China Medical Education Association

• Member of the Youth Club of the IBD Group of the Chinese Medical Association

• Member of IBD Expert Committee of Beijing Medical Award Foundation

• Vice Chairman of the Youth Committee of Digestive Endoscopy of Hunan Medical Association

• Deputy Head and Secretary of the Ultrasound Endoscopy Group of Hunan Medical Association

• Member and Secretary of Gastroenterologist Branch of Hunan Medical Association

• Contributing reviewer for Gastrointestinal endoscopy

Classic case one

The patient, female, 40 years old, complained of "diarrhea and blood in the stool for more than 1 month"
.

History of present illness:

In April 2021, the patient began to have diarrhea without obvious triggers, about 3-8 times/day, mixed with dark red blood, with persistent swelling pain in the lower abdomen, which was tolerable
.
Colonoscopy at the local hospital on May 11, 2021: Sigmoid and rectal mucosal changes: infectious enteritis? (CMV infection to be expelled); IBD？； Disease examination: mucosa has erosion, interstitial mass lymphocytes, plasma cells infiltrate
.
After anti-infection, mesalazine 4g/d, regulation of intestinal flora and other treatments, the symptoms did not improve significantly, and he was transferred to our hospital for treatment
on May 20.

Admission Assessment:

• Blood routine: WBC 6.
  13×10 9/L, Hb 90g/L↓, Plt 187×10⁹/L;

• C-reactive protein (CRP): 20.
  04mg/L↑;

• ESR: 61mm/hr↑;

• Fecal occult blood (OB): positive;

• Calprotectin: 1800 ug/g↑;

• Liver function: Alb 22.
  6g/L↓;

• Connective tissue: positive for P-ANCA (+), positive for anti-SS-A antibody (++), positive for anti-U1-RNP/Sm antibody (+);

• Cytomegalovirus (CMV) DNA: 1.
  009×10²cps/mL; Serum EBV-DNA: normal; Clostridium difficile test: negative
  .
  

• Colonoscopy: 30 cm from the anus, the colorectal mucosa is hyperemic and swollen, multiple deep chiseled ulcers of the sigmoid colon, diffuse superficial ulcers and erosions of the rectum, and purulent discharge (Figure 1).
  
  

Figure 1 Colonoscopy results of hospitalization

• Pathology: (rectal) moderately active chronic inflammation, cryptitis and crypt abscess can be seen, interstitial plethocyte, plasma cell and eosinophil infiltration, (sigmoid colon) ulcer formation, focal macrokaryocytes, combined with immunohistochemistry consistent with cytomegalovirus infection
  .
  

Admission diagnosis:

UC (E2, first-onset, severely active, Mayo score 11, CMV infection)

The treatment undergoes:

After admission, on June 1, 2021, vedelizumab 300mg intravenous drip, ganciclovir antiviral, anti-infection, regulation of intestinal flora, anticoagulation, nutritional support and other symptomatic supportive treatment were given, and the symptoms improved significantly on the third day after treatment, and the retest results on June 4, 2021 were as follows (Table 1):

Table 1 Comparison of indicators before and after initial treatment

Table 2 Comparison of various indicators after four treatments

Colonoscopy was repeated on September 8, 2021: the scope was inserted to the end of the ileum, the mucosa at the end of the ileum was smooth, the ileocecal valve could be opened and closed, the mucosa around the appendix foramen was smooth, and the entire large intestine was scattered with pseudopolyps and white ulcer scars (Fig.
2).

Figure 2 Results of colonoscopy after treatment

Classic case two

The patient, a 31-year-old male, complained of "intermittent diarrhea and mucus and bloody stools for more than 4 years"
.

History of present illness:

The patient had diarrhea in November 2017 without obvious triggers, 7-8 times/day, watery stool and mushy stool alternately, and then mucus and bloody stool, accompanied by tenesmus and persistent tingling pain in the left lower abdomen, after being admitted to our hospital to complete the relevant examinations, it was diagnosed as UC (E3, primary type, moderate), and his symptoms improved after treatment with mesalazine 4g/d, and he was treated regularly with mesalazine after discharge, and still intermittently had diarrhea, mucus and bloody stools, and was admitted to our hospital on May 11, 2021 for treatment
。

Admission Assessment:

• Blood routine: Hb 98g/L;

• C-reactive protein (CRP): 20.
  04mg/L;

• ESR: 56mm/hr;

• The rest of the laboratory indicators are basically normal
  .
  

• Colonoscopy: scattered patchy erosions at the end of the ileum, shallow ulcers with a diameter of about 0.
  3 cm, scattered patchy erosions and superficial ulcers in the sigmoid colon and rectum (Fig.
  3).
  
  

Figure 3 Colonoscopy results
of hospitalization

Admission diagnosis:

UC (E3, chronic relapse, moderately active, Mayo score: 10)

Diagnosis and treatment:

From November 2017 to May 2021, mesalazine 4g/d + mesalazine suppository + five-flavor bitter ginseng capsules were used, during which symptoms recurred;

On May 11, May 25, 2021, and June 25, 2021, he received vedelizumab 300mg continuous intravenous drip, and the results after treatment were as follows (Table 3):

Table 3 Comparison of indicators before and after treatment

Repeat colonoscopy on 16 August 2021 (Figure 4):

Figure 4 Results of colonoscopy after treatment